NHS White Paper

Lord Lansley Excerpts

Monday 12th July 2010 Commons Chamber

[The Secretary of State for Health (Mr Andrew Lansley)]

With permission, Mr Speaker, I would like to make a statement on the future of the national health service.

The NHS is one of our great institutions, and a symbol of our society’s solidarity and compassion. It is admired around the world for the comprehensive care it provides and for the quality, skill and dedication of its staff. I begin today by paying tribute to the staff of the NHS and the commitment they daily show to patients in their care.

This Government will always adhere to the core principles of the NHS: a comprehensive service for all, free at the point of use, based on need, not ability to pay. That principle of equity will be maintained, but we need the NHS also consistently to provide excellent care.

The NHS today faces great challenges: it must respond to the demands of an increasing and ageing population, advances in medical technology and rising expectations; it remains stifled by a culture of top-down bureaucracy, which blocks the creativity and innovation of its staff; and it does not deliver outcomes in line with the best health services internationally—many of our survival rates for disease are worse than those of our neighbours. The NHS must be equipped to meet those challenges. We believe it can do much better for patients, so today I am publishing the White Paper, “Equity and Excellence: Liberating the NHS”, so that we can put patients right at the heart of decisions made about their care, put clinicians in the driving seat on decisions about services, and focus the NHS on delivering health outcomes that are comparable with, or even better than, those of our international neighbours.

For too long, processes have come before outcomes, as NHS staff have had to contend with 100 targets and over 260,000 separate data returns to the Department each year. We will remove unjustified targets and the bureaucracy that sustains them. In their place, we will introduce an outcomes framework setting out what the service should achieve, leaving the professionals to develop how.

We should have clear ambitions, and our approach will be set out shortly in a further consultation document. For example, our aims could be: to achieve one and five-year cancer survival rates above the European average; to minimise avoidable hospital-acquired infections; and to increase the proportion of stroke victims who are able to go home and live independently—in short, care that is effective, safe and meets patients’ expectations.

The outcomes framework will be supported by clinically established quality standards, and the NHS will be geared across the board towards meeting them. We will do that by rewarding commissioners for delivering care in line with quality standards; strengthening the regulatory regime so that patients can be assured that services are safe; and reforming the payment system in the NHS, so that it is a driver not just for activity, but also for quality, efficiency and integrated care.

Patients will be at the heart of the new NHS. Our guiding principle will be “no decision about me, without me.” We will bring NHS resources and NHS decision making as close to the patient as possible. We will extend “personal budgets”, giving patients with long-term conditions real choices about their care. We will introduce real, local democratic accountability to health care for the first time in almost 40 years by giving local authorities the power to agree local strategies to bring the NHS, public health and social care together. Local authorities will also be given control over local health improvement budgets. This will give an unprecedented opportunity to link health and social care services together for patients. We will give general practices, working together in local consortiums, the responsibility for commissioning NHS services, so that they are able to respond to the wishes and needs of their patients. This principle is vital, bringing together the management of care with the management of resources. With commissioning support, GPs collectively will lead a bottom-up design of services.

In addition, we will introduce more say for patients at every stage of their care, extending the right to choose far beyond a choice of hospital. Patients will have choice over treatment options, where clinically appropriate, and the consultant-led team by whom they are treated. They will have the right to choose their GP practice, and they will have much greater access to information, including the power to control their patient record. We must ensure also that patients’ voices are heard, so we will establish HealthWatch nationally and locally, based on local involvement networks, to champion the needs of patients and the public at every level of the system.

To achieve these improvements in outcomes, we need to liberate the NHS from the old command-and-control regime, so all NHS trusts will become foundation trusts, freed from the constraints of top-down control, with power increasingly placed in the hands of their employees; and we will allow any willing provider to deliver services to NHS patients—provided that they can deliver the high-quality standards of care we expect from them. Our aim is to create the largest social enterprise sector in the world, but it is not a free-for-all. Monitor will become a stronger economic regulator to ensure that the services being provided are efficient and effective, and that every area of the country has the NHS services it needs to provide a comprehensive service to all. The Care Quality Commission will safeguard standards of safety and quality. An independent and accountable NHS Commissioning Board will be established to drive quality improvements through national guidance and standards, in order to inform GP-led commissioning. The board will allocate resources according to the needs of local areas, and lead specialised commissioning.

In the coming weeks, detailed consultation documents will enable people to comment on the implementation of this strategy, leading to the publication of a health Bill later this year. I recognise that the scale of today’s reforms is challenging, but they are designed to build on the best of what the NHS is already doing. Clinicians are already working to facilitate patient choice, giving patients the information they need to make effective decisions. GP consortiums are already established in some areas of the country and are ready to go. Local authorities in some areas are already working closely with local clinicians to co-ordinate health and social care and improve public health. Payment by results already gives us a starting framework for building a payment system that really drives performance. Foundation trusts are already using the freedoms they have to innovate. We will build on this progress, not dismantle it.

With this White Paper we are shifting power decisively towards patients and clinicians. We will seek out and support clinical leadership. That means simplifying the NHS landscape and taking a further, radical look at the whole range of public bodies. We will reduce the Department of Health’s NHS functions, delivering efficiency savings in administration. We will rebalance the NHS, reducing management costs by 45% over the next four years and abolishing quangos that do not need to exist, particularly if they do not meet the Government’s three tests for public bodies. We will also shift more than £1 billion from back-office to the front line. Form must follow function. As we empower the front line, so we must disempower the bureaucracy. Therefore, after a transitional period we will phase out the top-down management hierarchy, including both strategic health authorities and primary care trusts.

Later in the summer, we will be publishing a report setting out how we see the future of NHS-related quangos. I can say now that this will mean a reduction of at least a third in the number of such bodies. This is part of a wider drive across government to increase the accountability of public bodies and reduce their number and cost. The dismantling of this bureaucracy will help the NHS realise up to £20 billion of efficiency savings by 2014, all of which will be reinvested in patient care. Today’s reforms set out a long-term vision for an NHS that is led by patients and professionals, not by politicians. It sets out a vision for an NHS empowered to deliver health outcomes as good as any in the world. I commend this statement to the House.

[Andy Burnham (Leigh) (Lab)]

I thank the right hon. Gentleman for his statement and for giving me advance sight of it, although in keeping with the style of this Government, it would appear that this House was the last to find out, behind every media outlet in the land.

Last month, the Commonwealth Fund gave its verdict on Labour’s NHS, saying that it was top on efficiency and second overall on quality compared with other developed health care systems. Today, we have further evidence of progress, with figures from Cancer Research UK showing that long-term cancer survival rates have doubled. This progress was hard won; it took 10 years of painstaking work piecing together a detailed jigsaw. The right hon. Gentleman, with this White Paper, has today picked it up and thrown the pieces up in the air. It is a huge gamble with a national health service that is working well for patients.

The right hon. Gentleman’s spin operation bills this as

“the biggest revolution in the NHS since its foundation 60 years ago”.

That is something of a surprise, given the ink was barely dry on a coalition agreement that said:

“We will stop the top-down reorganisations of the NHS that have got in the way of patient care.”

What has happened since the publication of the coalition agreement to justify a U-turn of such epic proportions? Manifesto commitments have been casually dropped but this must be the first time that that agreement has been so spectacularly ripped up.

This reorganisation is the last thing that the NHS needs right now; it needs stability, not upheaval. All its energy must be focused on the financial challenge ahead. It needs confident, motivated staff, but the 1.3 million people who work for the NHS will not be comforted by this White Paper and they will be alarmed that their systems of national pay bargaining are being torn up. We support a strong say for clinicians and GPs in improving quality. That was the direction that Lord Darzi set out, after broad consultation. We introduced practice-based commissioning within a framework of public accountability and population-wide commissioning supported by primary care trusts. What we do not support is the wiping away of oversight and public accountability, and the handing over of £80 billion of public money to GPs, whether they are ready or not. Michael Dixon, chair of the NHS Alliance, says that only about 5% of GPs are ready to take over commissioning. Sir David Nicholson, chief executive of the NHS, has judged that even the best GP practice-based commissioners are “only about a three” out of 10 in terms of the quality of their commissioning. So what sound evidence does the right hon. Gentleman have that 100% of GPs are ready, willing and able to commission services for the entire population?

The right hon. Gentleman’s statement talked of rewarding commissioners who hit outcomes. Does he mean yet more money for GPs? How much will all GPs be paid for taking on this role? How many jobs does he expect to be lost in the NHS and how much money has he put aside for redundancy costs? What guarantees can he give the House that people will not simply be paid off by the NHS to be re-employed by a GP practice?

How does the right hon. Gentleman think loyal primary care trust staff felt when they read this quote—I apologise, in advance, for the language, Mr Speaker—from

“a senior Department of Health source”,

which was anonymously briefed to the Health Service Journal? It reads:

“PCTs are screwed. If you’ve got shares in PCTs I think you should sell”.

That is no way to treat loyal public servants, who have served the NHS and are now worried about their future. On page 10, the right hon. Gentleman says that the reforms are vital to deal with the financial situation, but is it not the case that there has never been an NHS reorganisation that did not cost money and divert resources in the short term? Is not the handing of the public budget to independent contractors tantamount to the privatisation of the commissioning function in the NHS? Will there be any restrictions at all on the use of the private sector by GPs?

Added to this, the right hon. Gentleman is bringing a series of market reforms into hospitals. He tells us that the first role of Monitor will be to promote competition and talks of any willing provider and freedoms for foundation trusts. Is not that the green light to let market forces rip right through the system with no checks or balances? Are not the hearts of NHS staff sinking as they read the White Paper?

On bureaucracy, we will support the Government where sensible reductions can be made, but what he calls pointless bureaucracy, we call essential regulation. What are his plans for the Food Standards Agency and are the reports correct that he has waived his right to regulate in return for funding for Change4Life? Can he explain how 500 or more GP consortiums, all of whom will need administration and management, can be less bureaucratic than 152 primary care trusts?

Lastly, where are the public accountability and the accountability to this House? How will GPs be held to account for the £80 billion of public money for which they will be responsible and how will the new NHS commissioning board—the biggest quango in the world—be accountable to this House and to Members of Parliament?

In conclusion, this White Paper represents a roll of the dice that puts the NHS at risk—a giant political experiment with no consultation, no piloting and no evidence. It is the right hon. Gentleman at his confused and muddled worst, but the sadness is that he is taking an £80 billion gamble with the great success story that is our national health service today. At a stroke, he is removing public accountability and opening the door to unchecked privatisation. He is demoralising NHS staff at just the time we need them at their motivated best. For patients, it opens the door to a new era of postcode prescribing where services vary from street to street. It turns order into chaos, and we will oppose it.

[Mr Lansley]

I am just astonished that the shadow Secretary of State seems to have gone to the barricades for the primary care trusts. The primary care trusts and strategic health authorities are organisations that, under his watch as Secretary of State—for about a year—increased their management costs by 23%. In the year for which he was in charge, they spent £261 million on management consultants. Before the election, when it had a majority of Labour Members, the Select Committee on Health said that PCT commissioning was weak and that it was not delivering what was intended. He set up a programme called world class commissioning—it never worked. Central to delivering better commissioning in the health service is ensuring that those people who incur the expenditure—the general practitioners, on behalf of their patients—and who decide about the referral of patients are the same people who, through the commissioning process, determine the shape of the services in their area. It is more accountable.

How often have all of us, on both sides of the House, asked Labour Ministers about what primary care trusts are doing locally in terms of service change only to be told, “It’s nothing to do with us; it’s all happening locally”? We are going to be very clear about the accountability. One thing that the coalition programme has enabled us to do, as two parties bringing our programmes together, is to strengthen the accountability to local authorities. Local authorities, through their strategies that mesh NHS services, public health and social care, will ensure that major service changes and the design of services reflect the interconnection between those things. Those who have complaints and problems will be able to have them addressed through HealthWatch and through their local authority. We will be able, through local authorities, to ensure that the commissioning support to GP commissioning consortiums can be more effective.

The shadow Secretary of State talked about the Commonwealth Fund. I do not know whether he has even read the Commonwealth Fund report, but it said that the UK health care system was the second worst on hospital-acquired infections, that the UK delivers the poorest level of patient-centred care and that, on outcomes, we performed the second worst overall on mortality amenable to health care.

The right hon. Gentleman stood up and said that cancer mortality rates have improved. They have—since the 1970s, and all over the world. However, the issue is where we stand in relation to the rest of the world. If we were to meet the European average on cancer survivals, 5,000 more people would live each year rather than die. If we were to do the best in Europe, 10,000 more would live each year. For stroke, the figure is 9,000. We have to measure ourselves on the outcomes relative to the other health systems that are comparable to ours.

Nine years ago, the right hon. Gentleman’s Prime Minister, Tony Blair, said that we must spend as much as Europe. Through this White Paper and the reforms that we will bring in, we are determined to achieve results for patients that are at least as good as those in the rest of Europe. It is not just about inputs and spending, but about the results we achieve. The right hon. Gentleman, on behalf of his party, has just abandoned the reforms that his Prime Minister, Tony Blair, put forward. In 2006, Tony Blair said that we must have patient choice, practice-based commissioning, the independent sector and foundation trusts—reforms that Labour failed to deliver and, indeed, undermined. We, as a coalition Government, are now determined to put those reforms in place to deliver results for patients.

[Mr Stephen Dorrell (Charnwood) (Con)]

I congratulate my right hon. Friend on setting out a clear vision for the NHS that is committed to high-quality outcomes for patients and good value for money for the taxpayer. Does he agree that the delivery of that objective depends critically on effective commissioning? Does he recall that the last Labour Government said that engaging GPs with the commissioning process was the key to success? Does he recall that the White Paper setting out the plan for practice-based commissioning said that GP commissioning was not a new idea to the NHS? Indeed, it is not. He is to be congratulated on holding out the prospect that, at last, this idea can be made good and made powerful in the interests of patients.

[Mr Lansley]

I am grateful to my right hon. Friend for his comments. In his capacity as the Chairman of the Select Committee on Health, we will be responding to him very shortly regarding the Select Committee’s report from before the election on commissioning in the NHS. What he has just said is absolutely right; we have to be able—this is a central task in commissioning—to bring together the responsibility for the management of patient care with the responsibility for the commissioning of services. The current situation is akin to a shopping trolley being pushed to the checkout while the primary care trust is standing there with a credit card, bleating about whether things should be taken out of the trolley. We have to ensure that the design of services follows the best clinical leadership in terms of the services that are required for patients. He and I very much agree on precisely that objective.

[Several hon. Members]

rose—

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[Caroline Flint (Don Valley) (Lab)]

Thank you, Mr Speaker. Is it not already the case, in PCTs, that it is clinical directors, who are professionally trained as doctors, who lead in terms of providing services in conjunction with GPs at a local level? Can the Secretary of State assure the House that his proposals will make the system any better? I do not think so.

[Mr Lansley]

I am sorry, but when the right hon. Lady was a Minister, she should have talked to more GPs. Overwhelmingly, they would have told her that they do not feel that the PCTs listen to them. They feel that the PCTs tell them what to do and get in the way. We are going to empower GPs to deliver services for their patients.

[David Tredinnick (Bosworth) (Con)]

I, too, congratulate my right hon. Friend on his statement. If he is going to get more choice for patients in treatment options, he will have to expand integrated health care so that herbal medicine, acupuncture, back treatments and homeopathy are more widely available across the country. Will he look at the American model of the consortium of 44 academies that has been considering integrated health care? Can he reassure me that his NHS commissioning board will not block options for integrated health care across the country?

[Mr Lansley]

The job of the NHS commissioning board will be to inform GP-led commissioning through scientific evidence, clinical evidence and guidelines, but it will be for GPs themselves, managing their budgets, to enable patients to exercise greater choice. The working out of what that choice looks like should not be dictated by politicians, but should be determined by patients and their clinical advisers.

[Miss Anne Begg (Aberdeen South) (Lab)]

The Secretary of State has not answered the question of my right hon. Friend the Member for Leigh (Andy Burnham) about the future of the Food Standards Agency. The Scottish arm of the FSA is based in Aberdeen, and I wonder whether the Secretary of State has had any discussions with the Scottish Government about its future. If not, is this yet another example of the new relationship that is meant to be in place between Scotland and the rest of the UK?

[Mr Lansley]

The shadow Secretary of State will have had the chance to see that there is nothing in today’s White Paper about the FSA—no such proposal.

[Andy Burnham]

You have been briefing about it.

[Mr Lansley]

I have not been briefing anything to anybody. [Interruption.] I have not. It is very straightforward. The FSA, along with other bodies associated with our public health responsibilities, will be the subject of a public health White Paper in the autumn. There is no proposal.

[Andrew George (St Ives) (LD)]

In seeking to reassure the House that this is not the top-down reorganisation that the coalition agreement derided, would my right hon. colleague reassure my constituents, who are quite excited by the idea of more patient and local authority involvement in local decision making, that where the primary care trusts in which they are going to be appointed will be abolished, there will be more GP commissioning groups than PCTs at the end of the process?

[Mr Lansley]

Yes, I am grateful to the hon. Gentleman. The number of GP-commissioning consortiums will be determined not least by GPs themselves, deciding what makes sense in their locality. He and his Cornish colleagues have often been frustrated by the way in which a top-down bureaucracy has sought to dictate to the people of Cornwall, often in specific localities, at a considerable distance from their hospital services, what services should be provided locally in places such as Hayle and Penzance. He and his constituents can be really comforted by the thought that their clinical advisers and general practitioners in local consortiums can in future make those decisions about their services.

[Hazel Blears (Salford and Eccles) (Lab)]

Despite the tremendous improvements that have been made in Salford and Eccles over the past few years in tackling cancer and heart disease, significant inequalities remain that require substantial resources. Will the Secretary of State confirm that in shifting commissioning powers to GPs and allowing the NHS commissioning board to allocate resources, the funding formula will still properly reflect the needs and deprivation factors in areas such as mine and right across the country?

[Mr Lansley]

The White Paper makes it clear that the NHS commissioning board will be required to allocate resources across the NHS in England on the basis, as far as possible, of seeking to secure equivalent access to NHS services. That will clearly be relative to the prospective burden of disease. In tackling health inequalities, the right hon. Lady will know that we need separately to allocate resources to local health improvement plans, which will be led through local authorities, and which will enable them to create local public health strategies to secure improvements in health outcomes and to reduce health inequalities.

[Nadine Dorries (Mid Bedfordshire) (Con)]

May I congratulate the Secretary of State on what is a truly exciting White Paper? Will he confirm that in addition to GPs having responsibility for commissioning, there will be the opportunity for them to become actively involved in the provision of care and deciding what care is allocated to which patients?

[Mr Lansley]

Yes, my hon. Friend understands that GPs are often providers beyond their primary medical services responsibilities. One of the difficulties with fundholding was that there was an opportunity for that conflict of interest to arise and not be properly resolved, so we have made it clear that, in the commissioning framework that we will publish, we will set out consultation proposals on how we ensure that that conflict of interest is not allowed to arise. Where GPs wish to be providers, we do not constrain them, but how that contract is arrived at is transparent and open.

[Mr Nick Raynsford (Greenwich and Woolwich) (Lab)]

How can the Secretary of State, with a straight face, say that he opposes the culture of top-down bureaucracy and decisions being taken by politicians, when he himself, in the past six weeks, has stopped the implementation of a clinically led and agreed programme for improving health care provision in south-east London, which was going ahead until he stopped it? Does he now accept that his words carry very little force for those of us who know what his actions indicate?

[Mr Lansley]

No is the answer. I set out on 21 May criteria on listening to patients and understanding what patient choice will be in future; on engaging the public, including local authorities, which are now following through on that accountability; on following the clinical evidence of what can best deliver outcomes; and on ensuring that GPs, as we have made clear, must be supportive and engaged. If any proposal in London is made at local level, such as the one the right hon. Gentleman refers to in Oxleas, that satisfies those criteria, which are bottom-up and locally led, there is no difficulty in its proceeding.

[Mr Steve Brine (Winchester) (Con)]

I congratulate the Secretary of State on his statement, which many people outside the House will recognise is a breath of fresh air for our NHS, unlike the flagging leadership bid we heard earlier—the second this afternoon—from the Opposition.

Will the Secretary of State confirm that the new consortiums of GPs can regain responsibility for out-of-hours care, the provision of which is a great worry for many of the people I represent across Winchester and Chandler’s Ford?

[Mr Lansley]

Yes. The commissioning responsibility will include urgent and out-of-hours care. I commend to my hon. Friend what the White Paper says about how we can deliver improvements in efficiency and effectiveness in terms of urgent care, 24 hours a day, seven days a week.

[Mr Dennis Skinner (Bolsover) (Lab)]

Speaking as someone with a successful outcome, twice, under the national health service in recent times, could the Secretary of State explain to me why these private elements within the NHS—that is, the GP practices—which are getting another £80 billion to spend are not going to be watched over by the primary care trusts or, seemingly, anybody else? Who is going to watch them spend that money—the private sector?

[Mr Lansley]

I am astonished that Labour Members are still attacking general practice. I thought that shadow Ministers—former Ministers—had had enough of doing that. [Interruption.] I will answer the hon. Gentleman. GP practices will be accountable to patients who exercise choice; accountable to their local authority, through which a strategy is established; and accountable to Parliament and to Ministers through the NHS commissioning board with which they will have their contract.

[Jacob Rees-Mogg (North East Somerset) (Con)]

In welcoming this statement, I wonder whether the Secretary of State will be able to put in place any interim measures for people such as a constituent of mine who have been prescribed life-prolonging cancer drugs such as Lapatinib but are being denied them.

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[Mr Lansley]

I am pleased to be able to tell my hon. Friend that as part of the coalition programme we have said that we will implement a cancer drugs fund from April 2011. Indeed, my ministerial colleagues—not least the Minister of State, Department of Health, the hon. Member for Sutton and Cheam (Mr Burstow)—and I are looking urgently at what we can do in the meantime to try to ensure that we no longer continue with a situation where patients do not have access to cancer drugs that are routinely available in other countries.

[Mr David Lammy (Tottenham) (Lab)]

Most people will recognise that GPs are at the cornerstone of the NHS, but also that since 1948 they have been independent practitioners running for-profit businesses. What safeguards has the Secretary of State put in place, and what is he doing about conflicts of interest? He said nothing about that in his statement. Is not what is proposed like asking pharmaceutical companies to be in charge of the NHS drugs bill?

[Mr Lansley]

I must not be unkind to the right hon. Gentleman, because he has not yet had a chance to read the White Paper—

[Mr Lammy]

It is here—I have read it.

[Mr Lansley]

That is my statement. When the right hon. Gentleman reads the White Paper, it will become obvious to him that, yes, we are looking to GPs to take responsibility for commissioning, but, unlike the problems that arose with fundholding, there will not be an opportunity for GPs to generate surpluses on their commissioning budget, and so money in their pocket. It will not work like that: there will be a clear separation between the commissioning budget and their personal budget. We will focus on the thing that really matters, which is GPs taking a commissioning responsibility in designing services.

[Nicholas Soames (Mid Sussex) (Con)]

I welcome the Secretary of State’s bold and imaginative statement on a White Paper that I am sure will be broadly welcomed in the NHS, not least because it will give people within the NHS the opportunity to give true vent to their creativity. Does he agree, however, that he is setting very demanding targets and challenges; and what time line does he envisage before this is finally implemented?

[Mr Lansley]

I am grateful to my hon. Friend. I will not go through the White Paper in detail now, but within it he will find that we look towards some GP commissioning consortiums taking an early adopter place from 2011-12, with consortiums generally taking, as it were, a shadow responsibility but not a legal responsibility in 2012-13, and then taking full responsibility, subject to the passage of the legislation to establish that, from April 2013 onwards—the point at which we anticipate that primary care trusts will be abolished.

[Liz Kendall (Leicester West) (Lab)]

The Minister will know that about 80% of patient contact with the NHS is in primary care. Will GP commissioning groups be allowed to commission GP and other primary care services from themselves, and if so, how will they be held to account for that decision?

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[Mr Lansley]

No, the NHS commissioning board will contract for the primary medical services provided by GPs themselves. GPs will commission for the additional services, including all the community and hospital services. There will be a combination of individual practices taking a responsibility, rewarded through their quality and outcomes framework for the service that they provide to their patients individually, and a general commissioning responsibility for those practices together with others in a local consortium.

[Ben Gummer (Ipswich) (Con)]

Could the Secretary of State confirm what will happen to those trusts that have not yet achieved foundation trust status and those that are in the middle of applying for it?

[Mr Lansley]

I am grateful for that question, because what is important is that we have coherent reform in relation to both commissioners and providers. That means that by 2013-14, we should not only have energised the commissioning process and patient choice but set free the hospital providers. My objective, set out in the White Paper, is that by that time all NHS trusts should become foundation trusts. We will need to put in place measures to support them to do that.

[Mr Geoffrey Robinson (Coventry North West) (Lab)]

Is the Secretary of State aware that those of us who listened to his speeches in opposition were much encouraged, but that with this first statement he has totally disillusioned everybody who believed that he was going to avoid the faults of the past? He has now introduced the biggest top-down, ill thought-through reorganisation that there has ever been in the NHS, and it has about as much chance of success as any previously introduced.

[Mr Lansley]

I would encourage the hon. Gentleman to go and talk to GPs in Warwickshire whom I have talked to, and to talk to those at Walsgrave about the freedoms that they want to enjoy.

I wish to make it absolutely clear to the hon. Gentleman that there is great consistency between what we said in opposition and what I am announcing today, but that there are some major improvements. Frankly, they have come about because of the conversations that I have had with my colleagues from the Liberal Democrat party. Not least, those conversations have enabled us to focus on the fact that instead of leaving what was a diminishing, residual role for primary care trusts, which withered on the vine, it is better and stronger for us to create a strategic responsibility for local authorities on public health and on joining up health and social care. That will allow us to remove the bureaucracy associated with PCTs, and it is more coherent and stronger than the proposals that we had in opposition.

[Dr Sarah Wollaston (Totnes) (Con)]

My right hon. Friend recognises how toxic many targets were in the NHS, but they were not all bad. There were some that ensured that standards were maintained—for example the two-week wait for cancer referrals. How will he ensure that standards are maintained when targets are abolished?

[Mr Lansley]

I am grateful to my hon. Friend, who is absolutely right. That is why, as I said in my statement, not only will we be clear about what we are trying to achieve—for example, where cancer is concerned, one and five-year survival rates at least as good as the European average and hopefully as good as any in Europe—but we will require the NHS to look towards clinically led, evidence-based quality standards that enable those working in the NHS to be clear about what constitutes quality. That will enable us to deliver those outcomes.

[Glenda Jackson (Hampstead and Kilburn) (Lab)]

Some of the greatest health inequalities occur in areas of the greatest deprivation, which are not infrequently areas that are not attractive to GPs. We also have in London a very large number of people who have never registered, and will never register, with a GP. They tend to use accident and emergency departments. How will their medical needs be presented to this top-down body, the NHS commissioning agent, when there can be no input from GPs? If I read the Secretary of State’s statement correctly, GPs’ recommendations will be disregarded by the NHS commissioning board.

[Mr Lansley]

I do not recognise the hon. Lady’s latter point. Some 7% of the population in London are not registered with a GP, which is one reason why commissioning consortiums of GPs will take responsibility for their locality, not just their registered patient population.

In relation to hospitals such as the Royal Free, one reason why the hon. Lady, I and other Members were campaigning against her Government before the election was that we recognised that we cannot shut down accident and emergency departments when patients are coming in the door by the tens of thousands because there is no alternative provision. The best way to design services in the community that better meet the needs of patients is through general practitioners designing them around the needs of their patients.

[Mr John Baron (Basildon and Billericay) (Con)]

I very much welcome the White Paper’s increased focus on improving outcomes, and particularly my right hon. Friend’s comments about the introduction of one-year and five-year cancer survival rates, for which the all-party group on cancer has been pushing. How does he envisage GP commissioning of cancer services improving with the White Paper, given that part of the problem is that a typical GP will see only eight new cancer presentations a year?

[Mr Lansley]

I pay tribute to my hon. Friend’s work. He will have noted that I deliberately said both one-year and five-year cancer survival rates—he made an important point about that. Clearly, there are many specialist commissioning services, which will become the NHS commissioning board’s responsibility. To that extent, GPs should not be expected to commission specialised services—they have little experience of that. However, GPs as commissioning consortiums, like primary care trusts at the moment, are capable of having a relationship with their cancer networks to establish the services that they need for their patients. Indeed, that applies more to GPs because many of the patients and those who work in cancer services to whom I speak are critical of the lack of awareness on the part of PCT commissioners of the available services. Those who work in cancer services do not believe that PCT commissioners understand the service that they provide. Not every GP understands every aspect of cancer care, but they are much better placed to work with cancer specialists to design the services.

[Mr Michael Meacher (Oldham West and Royton) (Lab)]

Given the transfer of £70 billion of NHS funds from PCTs to 500 GP consortiums, the vast majority of which have neither the expertise nor the inclination for such a huge administrative task and will have to buy in specialists from the private sector to do it for them, is not it clear that the real motive behind the reforms is to enable US multinational corporations, such as UnitedHealth, or UK corporations, such as BUPA or Virgin, to parcel out health care to the private sector on a vast scale?

[Mr Lansley]

No. That is completely wrong on all counts.

[Dr Julian Lewis (New Forest East) (Con)]

I congratulate my right hon. Friend on his firm grasp of the subject and on taking an axe to the forest of bureaucracy. As he proposes to phase out the strategic health authorities, may I nominate the South Central strategic health authority—he knows what is coming—because that would ensure that it was no longer able to waste hundreds of thousands of pounds of our money on fighting a hopeless legal case to impose fluoridation on a population, three quarters of whom have indicated that they do not want it?

[Mr Lansley]

Yes, I am indeed aware of precisely what my hon. Friend says and will certainly take it into account.

[Jeremy Corbyn (Islington North) (Lab)]

The Secretary of State has been asked by many Members about the accountability of GPs, and he has not answered. Some £80 billion is to be pumped through GPs, who will then buy in services. Who manages them? Who monitors them? Who checks on what they are doing? Will we get value for money or, as my right hon. Friend the Member for Oldham West and Royton (Mr Meacher) said, will the system in reality be administered by private health companies, just as GPs are private contractors in the NHS?

[Mr Lansley]

At the risk of repetition, let me say that GPs will be accountable to patients, who will exercise more control and choice. They will be accountable to the NHS commissioning board, which will hold their contracts, for financial control and for their performance, through the quality and outcomes framework. They will be accountable to their local authority for their strategy and for the co-ordination of public health services and social care.

[Jason McCartney (Colne Valley) (Con)]

Thousands of patients in my constituency are desperate for specialist maternity care to be returned to Huddersfield royal infirmary, which was downgraded under the previous Government. Does the White Paper make the return of consultant-led maternity services to Huddersfield more likely?

[Mr Lansley]

The White Paper will enable GPs in an area, plus their local public and their local authority, to make decisions about the shape of services rather than its being done by ministerial diktat.

[Alex Cunningham (Stockton North) (Lab)]

The Secretary of State referred to delivering for the patient. Will he guarantee that patients such as those who need a new knee or a new hip can expect their treatment in 18 weeks, or is it more likely to be 18 months under today’s proposals, as it was under the previous Tory Government?

[Mr Lansley]

Ah! That was one of the Opposition Whips’ handout questions, wasn’t it? I will tell the hon. Gentleman that actually, patients are more likely to get their treatment more quickly. Let me give him an example. Patients with rheumatoid arthritis need rapid treatment, but they were losing out and suffering as a consequence of the 18-week target, because hospitals were hitting 18 weeks, but not providing the care needed by those patients in the light of their conditions. We must focus on what is in the best interests of patients, not on what is in the best interests of political grandstanding.

[Bob Blackman (Harrow East) (Con)]

The Secretary of State’s announcement will be warmly welcomed in my constituency. On Friday, I went to see a group practice of 12 GPs who are totally frustrated by the local PCT. They are concerned that when the reforms are introduced, they will also be frustrated by the GP consortiums. Will my right hon. Friend give me some assurances on how the GP consortiums will be formed? What will happen if some GPs disagree with how a consortium is set up?

[Mr Lansley]

I can tell my hon. Friend that I am looking to GPs in a locality to create GP commissioning consortiums that represent an area. They must decide on the geography of that and make proposals. It will not be possible for GPs simply to say, “This is nothing to do with us,” because in future, we must expect GPs, who are senior professionals in public service and paid appropriately, to be responsible not only for the care of the individual patient in front of them, but collectively for the quality of care provided to their population at large.

[Ms Gisela Stuart (Birmingham, Edgbaston) (Lab)]

Prior to 1997, there was no cancer strategy and cancer was not a priority. The Secretary of State is absolutely right to make reaching European levels of one and five-year survival rates one of his priorities and an aspiration, but he knows very well that the one thing that is holding us back is the problem of early diagnosis. Precisely how does he think his abolition of targets and his woolly assurances will ensure early diagnosis? I will wager him that under his proposals, we will fall backwards rather than make progress.

[Mr Lansley]

Let me tell the hon. Lady that only just over 40% of those who were diagnosed with cancer actually came through the two-week wait process at all. She is right that it is very important that patients’ signs and symptoms should be identified at an earlier point and that they should have earlier diagnosis. Whom does she imagine is best placed to identify signs and symptoms and to take action on them other than patients and the GPs who are responsible for their care? [Interruption.] If Opposition Members stop interrupting from a sedentary position, I can continue. Actually, patients need—[Interruption.] The shadow Secretary of State should understand this, having held responsibility for it. For early diagnosis, awareness of signs and symptoms on the part of patients is critical. Only 30% of members of the public had any idea what cancer signs and symptoms were beyond the presence of a lump or swelling. We need to change such things and the responses of GPs to those early signs and symptoms.

[Mr Speaker]

Order. Members really should not chunter, witter or otherwise heckle from a sedentary position, because they thereby reduce their chances of getting in, or of their colleagues getting in.

[Margot James (Stourbridge) (Con)]

Older people and people with long-term medical conditions have not been well served by the division between health and social care, which has lasted many years. I congratulate the Secretary of State on his plan to give local authorities control over local health improvement budgets. Can he say any more about how those reforms will break down the barriers between health and social care?

[Mr Lansley]

I am grateful for my hon. Friend’s question. There is an unprecedented opportunity for local authorities and the NHS to create a much more integrated and effective strategy for health and social care working together. That is partly about focusing on outcomes, partly about listening to patients, and partly about extending personal budgets for patients, so that they themselves can break down such barriers. However, critically, it is also about local authorities exercising the responsibility that we will give them, plus their existing powers in relation to well-being right across their areas, to seal that working together, to deliver better public health and better integration between their social care responsibility and NHS commissioning plans.

[Tony Lloyd (Manchester Central) (Lab)]

Without any shame, the Secretary of State is introducing an internal market in the health service. In that context, how will he guarantee that GPs will not look for cheaper medicine rather than better medicine?

[Mr Lansley]

Because patients will have increased choice—[Hon. Members: “How?”] Because patients will make their choices on the quality of service they receive, because the service will be free to them.

[Dr John Pugh (Southport) (LD)]

The coalition agreement pledges to introduce true local democratic accountability through citizens actually being elected on to a health board. What can the Secretary of State do to persuade me—because he has not so far—that we will have local citizens, not doctors, making any decisions about the shape and configuration of local NHS services other than in public health, and will any of them be consulted about his structural changes or allowed to do things differently locally?

[Mr Lansley]

Yes. I feel very strongly that we have deliberately set out to improve local democratic accountability and we have found an effective mechanism for doing so. Local authorities will themselves have statutory powers to agree local strategies that encompass not only local health improvement, but the commissioning plans and the social care commissioning strategies locally. If a major service change is contemplated as a consequence, the commissioning consortiums will not be able to proceed without the agreement of the local authority through its joint strategic assessment. The White Paper makes it clear that if they do not agree, the local authority will continue to have the capacity to send the proposals to the independent reconfiguration panel and, if necessary, to the Secretary of State.

[Austin Mitchell (Great Grimsby) (Lab)]

May I tell the Secretary of State that north-east Lincolnshire has developed an effective care trust plus, which worked with the local authority to link care and health in exactly the way that he proposes, but the effect of his proposals on that trust will be to deprive it of most of its functions and cause it to issue redundancy notices to most of its staff. Has he heard of the old adage, “If it ain’t broke, don’t fix it”?

[Mr Lansley]

It is broke, and we are fixing it. We are fixing it because primary care trusts have not succeeded in delivering the outcomes that we are looking for, and they have consumed an enormous amount of money. I remind the hon. Gentleman that in the last year, at a time when we knew that there was a financial crisis facing the public sector and that the NHS would have to deliver more for less, the strategic health authorities and primary care trusts increased their management costs—not their spending on patients—by 23% in one year. It was outrageous.

[Jeremy Lefroy (Stafford) (Con)]

I thank my right hon. Friend for his statement. As he will know, concerns were expressed about the role played by Monitor in the authorisation of the Mid-Staffordshire NHS Foundation Trust. Does he have any plans to beef up Monitor’s role and ensure that it plays a better role in the future in the authorisation of trusts?

[Mr Lansley]

Yes, and hon. Members will see in the White Paper the way in which we can strengthen the role of Monitor. It is not just about the authorisation processes for foundation trusts, but a continuing responsibility for the quality and standard of care being provided in all our trusts, NHS trusts or foundation trusts. It is important to focus on quality, on what constitutes quality and on ensuring sufficient incentives to support quality. In addition, I hope that some of the lessons that will be learnt from the inquiry being conducted by Robert Francis QC will inform how we can put a better system in place.

[Paul Flynn (Newport West) (Lab)]

How much will be created in additional bureaucracy and new costs by dumping on GPs tasks for which they are not trained?

[Mr Lansley]

The hon. Gentleman has not talked to GPs across England who are keen to take on this responsibility. In the process, we will reduce the costs of bureaucracy in the NHS by more than £1 billion a year.

[Nick de Bois (Enfield North) (Con)]

Does the Secretary of State agree that where moratoriums are in place, practising GPs should be encouraged to seize the opportunity to determine the future of hospital accident and emergency departments, as with Chase Farm hospital in my constituency?

[Mr Lansley]

Yes, I very much agree. As he knows, his local GPs, patient representative groups and the local authority are already demonstrating how they can come together to devise the right solutions for the people of Enfield and the district around Chase Farm.

[Valerie Vaz (Walsall South) (Lab)]

The Secretary of State talks about choice in the NHS, but could he confirm that GPs will be given the choice to join a consortium?

[Mr Lansley]

GP practices will all have to be members of a consortium, otherwise it will not be possible for them collectively to commission emergency and urgent care, and they will need to do that.

[Clive Efford (Eltham) (Lab)]

The Secretary of State seems to misunderstand one thing. When patients go in to be treated by a GP, they expect to get the best possible treatment available. The Secretary of State said in an earlier answer that he would expect patients to have the knowledge of drugs to be able to determine whether a GP was supplying cheaper or better drugs. What local accountability will there be of GPs, what resources will be put into HealthWatch networks, what resources will be left available for local health improvement budgets, and what teeth will local authorities have to impose local health plans?

[Mr Speaker]

Order. That was four questions, to which one answer will suffice.

[Mr Lansley]

The answer is that I said no such thing as what the hon. Gentleman suggested, and the record will show that.

[Harriett Baldwin (West Worcestershire) (Con)]

I welcome the fact that my right hon. Friend has said that an extra £20 billion will be going into patient care by 2014. Can he clarify how much more that is under our Budget, compared with Labour’s Budget, which would have cut the NHS budget?

[Mr Lansley]

My hon. Friend is right. It appears that the Labour party’s policy is to cut the NHS. Our policy is to do something that Labour never achieved: deliver greater efficiency and greater productivity in the NHS, not least through the reforms that I have announced. Every penny saved will be a penny reinvested to the benefit of patient care.

[Meg Munn (Sheffield, Heeley) (Lab/Co-op)]

Sheffield is one of the areas that already has GP consortiums. They have been developing their relationships with the primary care trust and are now starting to make progress. What guarantee can the Secretary of State give to my constituents that today’s unwanted change will not set back that process and not cause significant problems with the progress that has already been made?

[Mr Lansley]

It is not an unwanted change. All over the country, GPs themselves have resisted the concept that they do what the primary care trust tells them to do, when they are better placed to design services on behalf of their patients. They can, and I know that the GP commissioning consortiums in many places will want to take on board the key teams in primary care trusts that they think would help them deliver commissioning. However, GP commissioning consortiums will not be required to do so, although they will be required to deliver better outcomes for their patients.

[Charlotte Leslie (Bristol North West) (Con)]

If hon. Members speak to GPs and professionals, who do not just sit here and talk about the NHS, but actually run it, day by day, they will find that it is not change or the White Paper that has caused demoralisation, but the machine-gun fire of targets and the monolith of management. The reason why that has caused so much demoralisation among the work force is that target box-ticking is so often different from the provision of quality care, as we have tragically seen in Staffordshire. Can my right hon. Friend reassure me that his reforms will mean that box-ticking is replaced by quality of care?

[Mr Lansley]

My hon. Friend is absolutely right and expresses her point superbly. The process is going to be about quality, not tick-box targets, and it is going to enable the front-line staff of the NHS to have not only access to the resources that they need, but the power to use them more effectively.

[Fiona Mactaggart (Slough) (Lab)]

Who will have the legal responsibility for delivering the Secretary of State’s welcome promise of a health care service free at the point of delivery? If we have expensive patients who are not being well treated by the GPs, what resource do we have, as Members of Parliament representing the interests of those patients?

[Mr Lansley]

The hon. Lady will see, in the White Paper and the subsequent legislation, the continuation of the existing legal framework, which does not allow additional charges to be levied inside the NHS.

[Derek Twigg (Halton) (Lab)]

It is interesting that the Secretary of State said in the statement, “We will allow any willing provider to deliver services to NHS patients”. Does he rule out any area of services in the NHS where private providers will be able to provide services?

[Mr Lansley]

I am adopting an any-willing-provider policy that was the policy of the hon. Gentleman’s Government, until the shadow Secretary of State abandoned it in September 2009 at the behest of the trade unions. I am adopting a policy designed to achieve the best possible care for patients by giving them access to all those who will deliver NHS services within NHS prices.

[Dr Daniel Poulter (Central Suffolk and North Ipswich) (Con)]

Is my right hon. Friend aware that Hartismere hospital in my constituency was closed by Suffolk PCT, while at the same time, the PCT was able to afford to spend £500,000 on opening a new car park for managers? Does he agree that community hospitals such as Hartismere are still a valuable part of health care and that the White Paper might see a return to valuing them once again?

[Mr Lansley]

I am grateful to my hon. Friend for that question. I did in fact visit Hartismere hospital with his predecessor, and I entirely sympathise with his point. At that time, the primary care trust in his part of Suffolk was regarded as “initiative central”. It had to pursue every initiative from the Department of Health, and the money just went out the door. Those initiatives lasted just a year or two and then disappeared. That is not the basis on which to design the national health service. GPs are an excellent basis for this work because they are committed to their areas, and to the patients they look after, in the long term.

[Alan Keen (Feltham and Heston) (Lab/Co-op)]

If the Secretary of State is correct in saying that we need clinicians and GPs to have more influence and even control over the commissioning process, will he explain why he does not simply legislate for them to take over the current trusts? That would achieve his aim immediately, and if any inefficiencies appeared and changes to the management commissioning structure were needed—whether in the present PCTs or following reorganisation—they could take place after a period of time. Instead, these slash and burn proposals are going to cost millions of pounds and cause a lot of disruption.

[Mr Lansley]

The simple answer is because GP commissioners want to create their own commissioning consortiums according to their own needs and local circumstances. They do not want to be saddled with the legislative structures and costs that currently bedevil primary care trusts.

[Rachel Reeves (Leeds West) (Lab)]

In my constituency, a local charity called Healthy Living Network Leeds is commissioned by the PCT to provide health services in the most deprived areas, including among the Traveller community. What guarantee can the Secretary of State give to my constituents that those community-based health services will continue, and that they will be overseen to ensure that those treatments continue in the most deprived areas?

[Mr Lansley]

The answer is that GP commissioning consortiums will have a responsibility that goes beyond their registered patient population, and that when they set out their commissioning plans, those plans will have to be agreed by the local authority. In the hon. Lady’s case, Leeds city council will have a responsibility to ensure, through its health improvement plan and through NHS commissioning, that the needs of groups such as Travellers are properly met.

[Sajid Javid (Bromsgrove) (Con)]

My right hon. Friend will know that community hospitals, including The Princess of Wales community hospital in my constituency, have been under threat because of the policies of the previous Government. Does he agree that these new initiatives will make it more likely that local communities will take back control of their health care?

[Mr Lansley]

Yes, exactly. Last Thursday I was in Cumbria, and that is exactly what has happened there. The GP commissioners have collectively taken over responsibility for the Cockermouth community hospital. Instead of its being run down, as was intended, they have built it up as a base from which they are providing services for their area.

[Andrew Gwynne (Denton and Reddish) (Lab)]

Given that not all primary care trusts are coterminous with local authority areas, how will the public health aspect of the reorganisation be dealt with in areas such as Tameside and Glossop? It will not be as simple as just moving functions across to a single local authority in an area where a single health economy is greater than just one district.

[Mr Lansley]

As I am proposing to abolish primary care trusts, the problem of a lack of coterminosity will no longer apply. Health improvement plans, led by local authorities, will be set out on a basis consistent with many of the other services that make a significant contribution to delivering the kind of health and well-being that we are looking for.

[Emma Reynolds (Wolverhampton North East) (Lab)]

Wolverhampton primary care trust, working closely with GPs, has been at the forefront of driving improvements throughout Wolverhampton. For example, there has been a reduction in teenage pregnancies and in infant mortality. What evidence does the Secretary of State have that GP-led consortiums will be better placed than primary care trusts to carry forward further improvements in those areas, which affect the poorest communities in my constituency?

[Mr Lansley]

There is good evidence that physician-led commissioning of services for patients is very effective. Precedents in this country and across the world have shown that. The hon. Lady mentioned teenage pregnancy and infant mortality, and this is principally about the relationship between NHS services and wider public health services. Given such responsibility, I am sure that the local authority will be able to deliver local health improvement strategies that will impact on those factors more effectively than has been possible with the NHS doing it solely using NHS services and resources.

[Chris Leslie (Nottingham East) (Lab/Co-op)]

If the Secretary of State is going to force GPs to spend all this extra time on bureaucracy and managing the NHS, does it not mean that they will have less time to spend with their patients? Is that the reason why he scrapped patients’ right to see a GP within 48 hours?

[Mr Lansley]

Many GPs will find that they spend much less time trying to negotiate services for their patients through a PCT and NHS bureaucracy that get in the way. Of course GPs are operating collectively in a commissioning consortium, and I am not going to turn them into individual managers. Some GPs will be leaders—I am looking for clinical leadership—but they will also look for commissioning support. They can derive that from existing primary care trust teams if they think they are doing a good job; they can do it via local authorities or from independent sector providers of commissioning services as well.

[Joan Walley (Stoke-on-Trent North) (Lab)]

Does the Secretary of State not realise that there are greater health inequalities in some parts of the country, as in Stoke-on-Trent? Can he explain how this new arrangement of GP-led commissioning is going to deal with those health inequalities? Is it all going to be rolled out at one and the same time, or will there be pilot projects as part of a rolled-out programme? How is he going to ensure that health inequalities are dealt with, when local authorities in Stoke-on-Trent have to make £70 million of cuts over the next three years? How is it all going to be provided for?

--- Later in debate ---

[Mr Lansley]

It would be a good idea if Labour Members at least acknowledged that over the last 13 years health inequalities have widened in this country. We have not achieved health outcomes here that are at least as good as the European average, and in some respects regarding some diseases we are among the worst in Europe. We are going to turn this around. In order to do so, we are going to work not only with national strategies but with local strategies that are geared towards identifying those health inequalities and that expressly set out to reduce inequalities by looking beyond the NHS. Local authorities, the NHS, social care, the community and the voluntary sector will work together to make it happen.

[Alison Seabeck (Plymouth, Moor View) (Lab)]

The right hon. Gentleman talks about empowering GPs—some willingly and some unwillingly, I suspect. Some of them will need upskilling and training in order to understand the new process. What assessment has he made of the time GPs will need to devote to their training, and that of their staff, and of how much it will cost—or will GPs themselves be expected to pay for it?

[Mr Lansley]

I wonder whether the hon. Lady has met doctors in Devon. I have been to their local medical committee conference and discussed these issues with them. They are keen to go. If there was any difficulty, it was that at least one Plymouth GP had very high referral rates. I do not think he had ever checked those rates with his colleagues. It was interesting to hear them talk to one another. It became perfectly obvious that peer review—that sense of working collectively to manage services in an area—is going to hold GPs to account very effectively within consortiums as well. [Interruption.] The hon. Lady and all her colleagues completely underestimate the capacity of general practitioners, who are responsible for the overwhelming majority of patient contact in the NHS, not only to take on the responsibility of deciding whether they should incur the expenditure for the referrals they make but to have a say in designing those services.