NHS Future Forum

Lord Sawyer Excerpts

Thursday 15th September 2011 Lords Chamber

[Lord Sawyer]

My Lords, I also thank my noble friend Lady Wheeler for initiating this debate. It is very clear that the passage of the Health and Social Care Bill has been troubled and that deep-seated concerns have been expressed by stakeholders across the health sector over the past few months. The Government have made some changes to their NHS reform proposals following the legislative pause and listening exercise, overseen by the NHS Future Forum. What was put forward by the forum was seen by many as a workable set of recommendations, and in fact 16 were made in all. However, the Government’s efforts to take forward revisions to the Bill based on those recommendations have led to further serious questions from all sides. In some areas the recommended changes have not gone far enough or have been missed altogether, and even where there have been improvements, there are serious worries that they have been made at the cost of introducing new complexity and bureaucracy into the National Health Service. An already multifarious piece of legislation is sadly becoming even more complicated.

The Government have made some effort to listen to and address some of the concerns that have been expressed about the Bill to date. Despite some improvements over the summer and despite there being some positive aspects to the reforms, it is apparent that real, deep-seated problems remain.

An unbelievably wide range of voices in the health sector, such as the NHS Confederation, the King’s Fund, patient bodies as well as trade unions including the British Medical Association and Unison, have expressed concern about the unacceptably high risk posed to the health service in England as a result of the Bill. That is why those organisations are calling for the Bill to be withdrawn, or at least to be substantially amended, before matters proceed.

I agree with my noble friend Lord Rea that the Bill continues to place inappropriate and misguided reliance on market forces to shape services, which is lamentable. It is very clear that the general direction of policy travel, such as widening patient choice to any qualified provider across a much larger range of services, has the potential to destabilise local health economies. That is also implicit in the Bill, which embeds a more central role for choice without full consideration of the consequences and creates ambiguity about how the trade-offs between increasing patient choice and ensuring fair access, integrated care and improved efficiency should all be managed.

In addition, insufficient thought has been applied to the unintended knock-on effects and long-term consequences of proposals in the Bill, including for medical education and training, public health and the patient-doctor relationship. Excessive complexity and bureaucracy are associated with the changes made to the Bill to counter the lack of proper checks and balances in the original proposals. Furthermore, much detail is still lacking, being left to subsequent regulations and guidance.

The focus on the changes flowing from the reforms is already creating a noticeable distraction from efforts to ensure and improve the quality of patient care today. Anybody who works in the health service, as I do from time to time, must be distraught at the time-consuming issues that employees have to tolerate and the uncertainty that arises from the proposed legislation. This is at a time when the NHS is expected to find an unprecedented £20 billion in efficiency savings over four years. What is happening is quite remarkable.

There are still many areas that need to be addressed. The Bill seeks to ensure that the Secretary of State retains overall responsibility,

“to secure that services are provided”,

while giving operational independence for the delivery of healthcare to numerous bodies, most notably the NHS Commissioning Board and clinical commissioning groups. This has been the subject of much debate and will no doubt continue to be so, but most outside organisations believe that insufficient assurance has yet to be given that the Secretary of State will have ultimate responsibility for the provision of a comprehensive health service while allowing other bodies such as the commissioning board day-to-day operational independence. There are still big questions to be answered in that area.

The Bill establishes a new system of economic regulation of health and social care. However, there should not be a reliance on market-based policies that risk further fragmentation and destabilisation of the National Health Service. Increasing patient choice should not be a higher priority than tackling fair access and health inequalities, meeting need, promoting integrated care and optimising resources. Those are the things that should be properly reflected, underlined and given priority in any legislation.

The proposals relating to public health still require further changes. Public Health England should be established as a special health authority of the National Health Service and all specialist public health staff should be employed on national NHS terms and conditions of service. It is also important for directors of public health to be made accountable jointly to the chief executive of the local authority which they serve and to Public Health England.

It has already been said by other noble Lords that an effective education and training system is fundamental to preparing a suitably trained workforce for the future. To achieve this, oversight of education and training must occur simultaneously at both national and regional levels. The structural reforms proposed by the Bill must not undermine this. The Government say that they will bring forward amendments to safeguard education and training. I look forward to seeing the detail of those proposals.

There must be a robust and transparent process which has the full confidence of the NHS when it comes to how failing trusts are dealt with, in order to protect the interests of patients and the public. The Government have reversed proposals to use private sector insolvency processes to manage NHS provider “failure” and introduced amendments in the other place outlining new proposals. However, it is important to ensure that these proposals are sufficiently robust to do the job. Questions about this will need to be asked when the Bill reaches this House.

Despite the numerous changes made to the Bill and movements in policy following recommendations from the Future Forum, more work needs to be done to ensure that the Bill does not pose significant risks to the future of the National Health Service. If the forum makes further recommendations, they should be listened to and acted upon.