Health and Social Care Bill

Lord Low of Dalston Excerpts

Tuesday 11th October 2011 Lords Chamber

[Lord Low of Dalston]

My Lords, this Bill would entrench—for it has already begun—the most radical reorganisation of the National Health Service since it was founded over 60 years ago.

I share all the concerns which the experts have articulated as flowing from the marketisation of healthcare along American lines: that is to say, in the direction of a system that is twice as expensive and much less efficient than ours. There is the impossibility of rational planning, the fragmentation of purchasing and procurement arrangements among hundreds of different entities, with the consequent loss of economies of scale. There is the embedding of incentives to physician-induced and supplier-induced demand—which the noble Baroness, Lady Williams, illustrated so graphically—leading to unnecessary tests and treatments, the diagnosis of minor problems as major, and over-aggressive treatments that might actually harm the patients subjected to them, all undertaken to increase provider income. That is not to mention the proliferation of bureaucracy required to administer the byzantine commissioning and contracting process.

The noble Lord, Lord Hennessy, said on the radio this morning that the NHS was about the nearest thing we had to the institutionalisation of altruism. The Bill, laden as it is with incentives for opportunistic behaviour, drives in entirely the opposite direction and bids fair to dismantle that system.

As Dr Lucy Reynolds and Professor Martin McKee have said, the ethics of the medical profession may provide a safeguard against patient exploitation, but unnecessarily putting temptation in doctors’ way is surely unwise. How much more is that the case—as the noble Baroness, Lady Bakewell, demonstrated earlier to such devastating effect—with healthcare providers whose sole objective is to turn a profit, with all the dangers that that presents of asset-stripping and cherry-picking among the low hanging fruit, in the clearest illustration of the conflict between commercial and social values, of which the noble Baroness, Lady Jay, spoke earlier, echoing the words of Aneurin Bevan?

There is already the risk of destabilisation as a result of the Government's determination to charge ahead. If ever there was a case of implementation before legislation, with consultation coming a poor third, this is it. Only this weekend, someone wrote to me saying:

“Some of our close friends are now experiencing not only lengthening waiting lists but inefficient follow-up procedure appointments as the cuts deepen and changes are already being made in many areas of the health service”.

There is little I can add in this vein to what those better versed in these matters have said. Instead, I will concretely illustrate the problems to which the legislation gives rise by reference to the field of eye health. Your Lordships would not expect me to speak without alluding to eye health. While declaring my interest as a vice-president of the RNIB, I have no compunction in doing so because it provides such a good illustration of many of the concerns held by critics of the legislation.

There are four particular concerns about eye health services that I would like to put to the Minister. The first is that of fragmentation. We currently have eye departments across England and Wales that provide a generally high level of care. They offer a comprehensive range of treatments for the main eye conditions, including cataracts, age-related macular degeneration, diabetic eye disease and glaucoma. However, with any qualified provider, this is likely to be quickly eroded with the disappearance of, for example, straightforward cataract surgery to private providers. Although that may be presented as a contribution to the QIPP agenda, it will have many unintended and damaging consequences.

Who, for example, will deal with the more complex operations and the inevitable complications? How do eye departments put together full and efficient operating lists? How can a smaller and fragmented eye department provide effective training for the next generation of ophthalmologists? How is an effective and comprehensive eye emergency service to be delivered?

A second concern relates to the failure so far to place eye health at the centre of the Government’s public health agenda. With an ageing population, visual impairment and blindness are now a bigger public health challenge to quality of life and cost—estimated at £22 billion in 2008—than the major killer diseases. It is all the more galling that 50 per cent of this is estimated to be preventable through early diagnosis and intervention.

The UK Vision Strategy, a coalition of all the major players in the vision impairment sector—the Royal College of Ophthalmologists, the Optical Confederation and the RNIB—has been arguing strongly for an ophthalmic public health indicator for avoiding blindness in the national framework. This would provide focus for clinical commissioning groups, health and well-being boards and Public Health England in this important area. However, it is increasingly concerned that such an indicator will not be included in the final framework when it is published later this year. That would be a major opportunity missed.

My third concern is about integrated planning and delivery across health, social care and health-related services. The establishment of local health and well-being boards to promote co-ordinated planning is to be welcomed. It is here that commissioners of health, social care and public health services will come together to develop the local joint health and well-being strategies adumbrated in Clauses 190 and 191. However, whether this can be an efficient and effective process with two to three times as many commissioning groups as at present—300 to 450 clinical commissioning groups in future, compared with 152 PCTs—must be in doubt.

My fourth concern relates to the role of NICE within the new framework. In their response to the NHS Future Forum, the Government confirmed that the funding direction requiring NHS commissioners to fund drugs and treatments in line with NICE’s recommendations would still apply until at least 2014, when value-based pricing will be introduced. However, enforcing the funding direction is already proving difficult—for example, in relation to anti-VEGF treatments used for the treatment of wet age-related macular degeneration. What reassurances can the Government offer patients that, from 2014, value-based pricing will not restrict access to innovative treatments? How will the funding direction be enforced in the event that a clinical commissioning group chooses to exercise local autonomy—for instance, where it faces serious cost pressures? It would be very helpful to have this clarified so that patients who develop eye problems and other health conditions can have confidence that drugs or treatments recommended by NICE will still be available to them.