Health and Social Care Bill

Lord Tugendhat Excerpts

Tuesday 11th October 2011 Lords Chamber

[Lord Tugendhat]

My Lords, I declare an interest as chairman of the Imperial College Healthcare NHS Trust. I begin by paying tribute to the staff of the NHS. They have had to respond to a bewildering set of changes, of direction, of organisational structures and of objectives during the past 15 months. All have played their part in keeping the show on the road but a particular word of praise should go to the managerial staff who are so often and so unfairly traduced in this House and indeed in the other place. It is they who are at the greatest risk of having their jobs merged or cut and it is they who are having to bear the particular burden of implementing some of the changes, many of which are caught somewhere between their departure point and their destination. Those staff deserve a considerable vote of confidence.

I speak as someone who is in favour of change in the NHS. Indeed, I have done my bit to promote it. I chaired the steering committee that brought about the merger of the former Hammersmith Hospitals Trust and the St Mary’s Hospital Trust to create the Imperial College Healthcare Trust, which is one of the largest in the country. I have also been deeply involved in the creation of the Academic Health Science Centre, which comprises my trust and Imperial College. It is one of only five academic health science centres in the country and one of the most exciting innovations to have occurred in the National Health Service for a very long time.

I give that background because I want it to be clear that when I say that the Government were unwise to introduce the Bill, I am not against change—far from it. I support much of what the Government are trying to achieve: enhancing patient choice, foundation trust hospitals, the reduction in administrative structures, more efficient decision-making, the reconfiguration of services, more use, where appropriate, of private providers and more involvement of general practitioners in commissioning. I could go on. I do not agree with everything in the Bill by any means but I agree with a great deal of it.

The Government’s mistake was to introduce a Bill that sought to impose a massive programme of management and structural change on top of an ambitious cost-cutting programme. I refer, of course, to what is now known as the Nicholson challenge—to make efficiency savings of £20 billion between 2011 and 2014. As many noble Lords will know, that is quite unprecedented and in itself is a huge and effective agent of change. The achievement of the Nicholson challenge is also of considerable importance to the Government’s economic policy. In my view, the Government should have used the Nicholson challenge as their great engine of change. They should also have recognised that much of what they wish to achieve in relation to patient choice, FT hospitals, service reconfiguration, private providers and involving GPs in commissioning, could, as other noble Lords have pointed out, have been achieved by building on what the previous Government had done with little or no recourse to primary legislation. If the Government had proceeded in that way and been more selective in their objectives, they could have achieved more, to the practical benefit of the NHS, of patients and of their own economic policy. They could also have avoided what can only be described as a haemorrhage of political capital.

So what is to be done? In my opinion, at this stage there can be no going back. There has been too much change already, too many administrative structures have been dissolved and are in the process of being reformed, and too many objectives and policies are uncertain and in a state of flux. The eggs have been broken but the omelette has not been made. Although the Bill is in need of a good deal of improvement and will no doubt, rightly, be subjected to a good deal of amendment, the National Health Service needs closure. It needs the stability that only the statute book can provide. I therefore urge noble Lords to reject the amendment in the names of the noble Lords, Lord Owen and Lord Hennessy. I understand what lies behind it and the advantages that they seek, but the NHS now requires closure and stability. I am struck by the fact that other noble Lords who are themselves directly involved in the NHS all appear to share this view.

In the time allotted to me, I cannot deal with many of the big issues already raised in this debate. Rather than touch on several in an inadequate fashion, I shall concentrate on one that I consider of critical importance. I refer to service reconfiguration, those slightly fancy words used to cover the rationalisation of services, their concentration on fewer sites and the scaling back of some hospitals. At present, there is too much duplication of services on too many sites. Too much is being done in hospitals that ought to be done in surgeries and at home. This is both needlessly costly and clinically unsound. There is a mass of evidence that shows that clinical standards improve if some specialist services are concentrated in bigger centres so that surgeons can perform complex operations more often and more regularly. The same applies not just to operations but to other treatments. This also facilitates investment in expensive state-of-the-art equipment. Likewise, modern medicine can often offer better care by getting patients out of hospitals and moving services into the community.

As we all know, it is hard to convince the general public of both those propositions. Shifting services from one site to another and scaling back hospitals, let alone closing them, causes acute local anguish and corresponding political protest. Of course it requires, and should require, extensive local consultation. My fear is that some of the new structures and procedures introduced in the Bill will make that consultation and those procedures even more complicated than they are at present—or, rather, than they were before the Bill was introduced. As a result, there is a big danger that the changes will not be undertaken on a planned and rational basis that takes due account of patient needs and clinical requirements; rather, they will be salami sliced in an ad hoc fashion in order to get around consultative procedures and to meet arbitrary deadlines.

The NHS is already under intense financial pressure that is bound to lead to some diminution of services. Ministers would do well to warn the country more loudly than they have of what is in store. It is vital, though, that as far as possible—and it will not always be possible—financial requirements should go with rather than against the grain of patient needs and clinical priorities. With that in mind, I hope that the Government will give serious consideration to a proposal from the King’s Fund, designed to depoliticise this process as far as possible. The proposal is that instead of the Secretary of State, the Independent Reconfiguration Panel should act as the final arbiter on reconfiguration proposals. I think that the King’s Fund is right when it argues that this would make the process more transparent and send a strong message to the local level that political considerations would not be the deciding factor, as they have so often been in the past. I believe, too, that this would speed up the process, which would be in the interest of clinical priorities and of meeting the Nicholson challenge. It would also be in line with the argument, in Liberating the NHS, that the Secretary of State should concern himself less with operational detail and more with strategic direction.