Dental Services: East of England

Richard Bacon Excerpts

Tuesday 16th May 2023 Westminster Hall

[Mr Richard Bacon (South Norfolk) (Con)]

I beg to move,

That this House has considered dental services in the East of England.

It is a pleasure to serve under your chairmanship, Sir Mark. I am particularly pleased to have the opportunity to introduce this debate on dental services in the east of England, as I have been applying to Mr Speaker for a debate on the subject for several months. I am sure that I am not alone among hon. Members in finding that the subject of access to a dentist is one of the largest in my constituency postbag and inbox. It has been the topic of numerous Back-Bench debates in recent times. I pay particular tribute to the efforts of my hon. Friend the Member for Waveney (Peter Aldous) and the hon. Member for Bradford South (Judith Cummins), who have jointly sponsored a trio of debates in the last year or so, most recently on 27 April. My hon. Friend the Member for Broadland (Jerome Mayhew), who is also present, led an Adjournment debate on the need to establish a dental training college in East Anglia on 11 October last year. I will not say much more about that, but I ask the Minister to reconsider the Government’s position on it, because my hon. Friend made some very good points in that debate.

There have been many other interventions on many occasions by many hon. Members from both sides of the House. Indeed, another of my parliamentary neighbours, the hon. Member for Norwich South (Clive Lewis), secured question No. 1 in Prime Minister’s questions last week and asked about dentistry. He also managed to include a rather third-rate joke—something to do with rotten teeth and rotten Governments—but before he is tempted to repeat that, should he grace us with his presence, I point out to the House that I have a fourth-rate joke just for him. Colleagues may have noticed that the debate was scheduled to start, and indeed did start on time, at tooth-hurty pm.

Given the—[Laughter.] It got there eventually. That is Lincolnshire for you, Sir Mark. Given the enormous cost of dealing with the pandemic, and the inevitable financial consequences and constraints that it imposed, I think that the Government have done rather well, but that is not to say that they cannot do better. We all expect them to do better, as do our constituents. The Commons Health Committee has studied the reform of dental services and noted concerns that the Government have

“transferred financial risk from the NHS to dentists”,

adding:

“The fixed-term contract may make dentists reluctant to make long term investments in their practice.”

The Committee observed that the chief dental officer appeared in evidence to argue that if commissioners and dentists

“acted more flexibly and used common sense and good will the new arrangements would work”,

but it concluded that

“we see little evidence that this will happen.”

The Committee also reported that the total number of dentists working for the NHS and the activity that they have provided has fallen, and that the total number of patients seen by an NHS dentist has fallen by 900,000. The conclusion of the Health Committee was that the contract was

“failing to improve dental services measured by any of the criteria.”

If hon. Members find any of those conclusions eerily familiar, it would not surprise me, because they are from the Health Committee’s report in July 2008, when the Committee had a Labour majority and a Labour Chair, and there was a Labour Government. I hope that we can all agree that this is a long-standing problem that is not confined to any one Government or party.

There is widespread agreement that the dental contract introduced in 2006 lies at the root of many of the problems that we see today. The old item of service method that existed prior to the 2006 contract may have had some issues, but as one dentist said to me:

“It was a system that allowed you to be entrepreneurial”.

A dentist could set up a dental practice, put a sign outside and get on with it. Under the old NHS contract, dentists were paid for each item of treatment that they provided—an examination, a filling, a crown or a denture. Now they are paid per course of treatment, irrespective of how many items are provided, thus a course of treatment involving one filling attracts the same fee as one containing five fillings, a root treatment and an extraction. As the Duke of Norfolk is rumoured to have said about the rhythm method of contraception, there is only one problem: it “doesn’t bloody work”. We have had this problem since 2006. We have a contract that is, effectively, not fit for purpose.

In fairness, the problems go back beyond 2006. Indeed, my hon. Friend the Member for Waveney said in his last debate on the subject on 27 April:

“The fundamental causes of the collapse of NHS dentistry”

—I do not like saying that as a supporter of the Government, but I do not think the “collapse of NHS dentistry” is too extreme when we see what is happening; I hope that the Minister notes that—

“go back over 25 years with a gradual withdrawal of funding by successive Governments and the poorly thought-through 2006 NHS contract.”

My hon. Friend added:

“Covid was the final straw that brought the edifice crashing down.”—[Official Report, 27 April 2023; Vol. 731, c. 995.]

The problems in NHS dentistry have been so well canvassed in so many recent debates that I do not want to rehearse them again. I will, however, reprise one story from my constituency. The Manor House dental practice in Long Stratton in South Norfolk was run for many years by a respected and successful dentist called Dr Mark Ter-Berg, who, after many years of service, retired and sold his practice. After a period, the new managers of the practice got into financial difficulty and the business went under, owing money both to its corporate owners and the NHS. Dr Ter-Berg offered to come out of retirement and take over his old practice. He was quoted as saying in a local newspaper:

“You would have thought that”—

NHS England—

would have bitten my hand off”.

After months of making the offer and getting nowhere, I intervened on his behalf with NHS England, but it did not make much difference.

Dr Ter-Berg finally gave up waiting and decided instead to set up an entirely separate new dental practice in Long Stratton. I drove past it the other day, and there was a sign that read, “Open from 4 May”. I spoke to him yesterday and he is now very busy. He does not have an NHS dental contract; it is all private work and he is extremely busy—and Long Stratton is not by any means the most prosperous part of my constituency.

As Allison Pearson wrote on 10 August 2022 in The Daily Telegraph, which is not a notable bastion of left-wing journalism:

“I can’t think of a better example of a two-tier NHS than the one that currently exists in dentistry.”

Indeed, I understand that the providers of dental plans—for example, Practice Plan, which styles itself

“the UK’s leading provider of practice-branded dental membership plans to help you leave NHS dentistry or switch providers”—

are so busy that they are rushed off their feet.

Colleagues will have seen the British Dental Association briefing for this debate, which references a much-reported BBC investigation showing that no dental practice in Norfolk, Suffolk or Cambridge was taking on new adult NHS patients, and that this was also true of nearly all dental practices in Hertfordshire, Bedfordshire and Essex. At the end of March, Bupa announced that it will close many dental practices across the country; 85 practices were to be affected, with 38 set to close immediately. That includes two in Norfolk, with one in Harleston in my South Norfolk constituency—although I understand that Bupa is hoping to sell that practice to a new owner and that it will not close on 30 June as previously expected. The truth is that successive Governments have made NHS dentistry a place where dentists increasingly do not want to work. We need to focus on that, and we would all like to know what the Minister will do about it.

Let me say a word about money. The thing that struck me most in preparing for this debate was how little money the NHS spends on dentistry—indeed, how little is spent on dentistry at all compared with what it spends on other things. The figure is currently about £3.2 billion a year—that fluctuates a bit—and about 20% to 32% of that is actually paid through patient charges, paid by the patients themselves.

A recent National Audit Office study showed NHS spending rising from £123.7 billion in the financial year that ended in 2020 up to £151.8 billion—more or less £152 billion—at the end of the financial year that just finished. Further big rises are expected and planned—going up to £162.6 billion—by the end of the financial year 2025. Those are huge sums. In comparison, the annual cost of dentistry is tiny. I tend to compare anything under £3 billion with the NHS national programme for IT in the health service—one of the less successful parts of the last Labour Government. The Health Committee and the Public Accounts Committee studied that extensively at the time, and showed that the electronic patient record element, which cost £2.7 billion, had achieved basically nothing. The Public Accounts Committee’s report—this was its third report on the issue—from around August 2011 stated:

“The Department is unable to show what has been achieved for the £2.7 billion spent to date on care records systems.”

In other words, that nearly £3 billion achieved precisely nothing. I know that this is not quite comparable, being an annual number, but talk of a few hundred million or a couple of billion pounds means a few failed Government computer projects, in terms of the quantum. Compared with the £124 billion or £152 billion or £160-something billion that we are talking about, £2 billion or £3 billion here or there is of very little account.

I am sure that the Minister will refer to the fact that the Government are aware they need to reform NHS dentistry and that he is working on a plan. Some hon. Members might press him for a date on that plan, but I will not do that. I am much more concerned about ensuring that, when he gets the plan, it is right. I do not think it is any one Government’s responsibility that this has gone wrong. In fairness to the Labour Government of the mid-00s, in 2006, they were trying to correct what they thought was a big problem—that the item of service method led to a bill that was difficult to control. It was more akin to annually managed expenditure in the social security Department.

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

My hon. Friend is making some very good points, and I congratulate him on securing the debate. He will recognise that there is a tension between payment by activity, which is not necessarily a desirable way to manage health—be that dental or physical health—and moving towards a more preventive model, which was the aim, if not the reality, of the changes to the 2006 contract and subsequent changes. What does he think about finding a way to lock in dentists to the NHS for maybe five years, post-graduation, to ensure that they pay back some of the training that cost the taxpayer many hundreds of thousands of pounds?

[Mr Bacon]

My hon. Friend makes several good points. We did payment by activity for acute hospitals, and we got a huge amount of activity in acute hospitals. Mental health was then the Cinderella service, with what little was left. Of course, there are tensions, and my hon. Friend, as a practising hospital doctor, will know that better than most. How that needle can be threaded to get the desired results has confronted Governments for many years.

On my hon. Friend’s specific point, having gone through medical school or dental school and come out the other end, junior doctors and, I am sure, junior dentists are at the moment struggling in the way that many others are—including young professionals—to afford anywhere to live. We have hundreds of thousands of acres of public land, including Ministry of Defence land, NHS land, railway land and church land, which has a quasi-public flavour to it. Norfolk County Council alone owns 16,000 acres of land. I would say to these people, “Come and work for the NHS for a few years full time. Commit yourselves completely to this, and we will help you design, build and rent from us at a decent rent. And then, depending on the calibrated loyalty package, which I am sure we can easily work out, you will get the chance in future to buy the house that you have designed for yourself.”

To go back to the point that my hon. Friend the Member for Broadland has made, getting people to stay in a particular area has proved difficult, not least because we do not have a dental training college. However, this is also about people understanding that the area they are going to work in is particularly attractive. That is true of much of the east of England, except people do not realise it because not enough of them, certainly in dentistry, are educated there. There is a huge opportunity for the Government to get this right, and I am more concerned about ensuring that the plan that comes from the Minister in the next few weeks or months is correct.

The fear I have is the potential downside. My constituent who, before Christmas, booked an appointment for her children for 9 May but found out recently that it was cancelled in a text message from the Harleston Bupa practice—she has been phoning to find out what is going on—will not care or know about the interstices of the 2006 dental contract, which was perhaps well intentioned but is deeply flawed and has led to many of the problems we are grappling with. She will just care that she cannot get an appointment.

Although the Opposition have not been particularly fleet of foot in recent years, even they can see that this will become a very salient issue at the next general election. We have our five points: halving inflation, growing the economy, reducing the national debt, cutting NHS waiting times and stopping the boats. Those are fine, but they are not a programme for Government. We need to do those things to restore confidence after the events of last autumn and—it might be best if I quote Mark Twain—to try and draw a veil and hope that not too many people remember them. However, the fact is that we need a better programme for the election, and I am sure we will have one.

The hon. Member for Denton and Reddish (Andrew Gwynne) will be sitting there with his chums, thinking, “What are our five points going to be?” If we do not get this right—mark my words, Sir Mark—the Opposition parties will say, “They have had 13 years to talk about it. It started with the 2006 dental contract, but they have had long enough and have not yet sorted it.” It will then become one of their five points. We are talking about such piffling sums of money compared with the overall cost of the NHS that it is simply incomprehensible that we would not deal with this properly.

The issue of dental care has been of growing concern to our constituents for many years, and the concern has only grown as successive Governments have failed to grapple with the issues properly. On present trends, it will continue to get worse—much worse—unless the Government make a decisive step change and match that decision with the right resources in the right places within a contractual framework that incentivises the right behaviour. That is what the Government need to do.

[Sir Mark Hendrick (in the Chair)]

I remind Members that they should bob if they wish to be called in the debate. I call Andrew Selous.

--- Later in debate ---

[Mr Richard Bacon]

I enjoyed listening to the remarks of every contributor, including my parliamentary neighbour, my hon. Friend the Member for Waveney (Peter Aldous). I was going to say “the Member for Aldous”—going around my constituency, one finds quite a lot of Aldouses; I have not yet established whether they are all related, but if one scrapes under a stone in East Anglia one quickly comes across an Aldous. He gave us a tour d’horizon—a tremendous summary of the expertise that he has gathered over the last few years. Together with the hon. Member for Bradford South (Judith Cummins), he has led the way in drawing the issue to the attention of other hon. Members. I pay tribute to him for that, and I am deeply in his debt, because reading his speeches was a great way to read my way into the subject—one that I was drawn to not because of any expertise, but because of my constituency postbag. We have heard that the same is true for all hon. Members.

Opinion pollsters are sometimes behind the curve on what is a salient issue, but hon. Members on both sides of the House know that this is the top issue facing us. My plea to the Minister is not to go so fast that he gets it wrong, but to bide his time and ensure that he has taken everything into account. He should talk to his Secretary of State, my right hon. Friend the Member for North East Cambridgeshire (Steve Barclay)—an east of England MP who has the same problems in his constituency postbag—and come up with an answer that is attractive and provides lasting change. That is what we want to see.

My hon. Friend the Member for Central Suffolk and North Ipswich (Dr Poulter), another of my parliamentary neighbours, raised the interesting point of how we encourage people who have had money spent on them by the NHS to stay in the NHS, even if they are paying fees themselves, as my hon. Friend the Member for South West Bedfordshire (Andrew Selous) said. I would be open to a wide variety of methods for doing that, including forgiveness of part of or perhaps all student loans. We need to make radical changes.

My hon. Friend the Member for Broadland (Jerome Mayhew) quoted a startling statistic: £80 per head is spent on dentistry in the areas that have the best dental care, and only £39 in parts of the east of England. What annoys me more than anything else is that, outside London and the south-east, the east of England is the fastest growing area of the country. It contributes the most gross value added to the economy outside London and the south-east. That is an argument that MPs in Norfolk and elsewhere in the east of England have been making for many years. We have been saying for years, “Give us the infrastructure, give us the broadband, give us the rail connectivity and give us the mobile telephony that actually works, without the need to go 100 yards down the road, stand on one leg and hope there is an “r” in the month to get a mobile telephone signal. Then we will provide the economic growth.”

Going back to the Prime Minister’s points, I seem to remember that one of them is about economic growth. Here we are contributing so much to the economy and yet not getting our fair share back, when the opportunity in the east of England is unrivalled in the UK. A golden triangle could exist between the economic heat, innovation and intellectual firepower of Cambridge; the Norwich Research Park in my constituency, where scientists look at world-leading advances in genomics and plant science; and technology in Ipswich at the BT labs at Martlesham. That golden triangle represents an extraordinary opportunity for the whole United Kingdom.

I was recently at the Cambridgeshire Development Forum, where I heard people talking about east-west rail and comparing themselves with Boston and Silicon Valley, but saying that they do not have enough room to grow. I say to my hon. Friend the Member for Boston and Skegness (Matt Warman) that that is, of course, Boston in America. The obvious answer is, “You have got loads of room to grow. You have got the whole of the east of England.” To an investor from Dubai or Shanghai, it all looks like Cambridge. We have a huge opportunity, but we need not only the infrastructure but the world’s best medical and dental services.

[Andrew Selous]

In an uncharacteristic slip and momentary lapse of memory, my hon. Friend forgot to mention the world-leading research in Cranfield, which I am sure he was going to add to his golden triangle of opportunities in the east of England. I am sure that that slipped his mind accidentally.

[Mr Richard Bacon]

It might make it more of a pentagram, but I did mean to mention Cranfield, of course. My hon. Friend knows that in South Norfolk we speak of little else. I do not want to take up too much time, although we are slightly ahead.

My hon. Friend the Member for Boston and Skegness said that he is not technically in the east of England. I had a mad great-great aunt who lived in Brigg in Lincolnshire, and Lincolnshire has always been in the east of England, as far as I am concerned. He is very welcome at this debate, and I had a great interest in what he said. However, if it is true that the wilder fringes of the internet have got worse in recent years, and if my hon. Friend was responsible for 5G, to whom should we attribute the extra growth in the wilder fringes of the internet, if not to him? I only pose the question.

The hon. Member for Denton and Reddish (Andrew Gwynne) surprised me. I remember when he was shadow Secretary of State for the Ministry of Housing, Communities and Local Government portfolio. He mostly appeared at the Dispatch Box like an angry avenging angel. The fact that he is capable of sounding rather rational and sensible was a surprise to me. I am afraid he also confirmed my worst fears—

[Sir Mark Hendrick (in the Chair)]

Order. Can we confine ourselves to the issue of dental services, please?

[Mr Richard Bacon]

As the hon. Member for Denton and Reddish said, dentistry definitely needs to be improved. He has confirmed my worst fear, which is that if the Minister does not focus on this sufficiently, the hon. Member and the Opposition will. They will produce a solution which—whether it is delivered or not—too many people will find attractive, I fear.

Fortunately, we have in the Minister someone in whom several colleagues have reposed confidence, and have said so publicly. On one occasion, when we were both on holiday, I bumped into the Minister in a second-hand book shop in Hay-on-Wye. I know he is a cerebral fellow who thinks carefully about these issues, and I take seriously the assurances I have had from colleagues that he is looking at this extremely closely.

I say one thing to him in conclusion, and this is the acid test. If he produces a dental plan that can be delivered speedily, and if he negotiates successfully not just with his Secretary of State and east of England MPs, but with the Treasury, to produce the resources required to do that, he will quickly give our constituents reassurance that NHS dental provision can be a place where dentists want to work, thrive and have successful careers. If he can do that, he will make a significant contribution to our success at the next general election. Not to put any pressure on him, but I believe that getting this right—reflecting on what I said about the issue being such a salient one—puts on his shoulders the enormous burden of getting the right answer so that our constituents have dental provision that works.

Question put and agreed to.

Resolved,

That this House has considered dental services in the East of England.

Health and Wellbeing Services: East of England

Richard Bacon Excerpts

Wednesday 1st March 2023 Westminster Hall

[Priti Patel]

The hon. Gentleman is right. For years, I have spoken about local healthcare provision. Practitioners know best, and it is not for central structures to dictate the needs of a local community. With that, there is the issue of access to services that matter so much. Dentistry has been controversial for too long. As a result, children are not accessing dentistry in the way they should, and health outcomes are absolutely shocking and appalling, particularly in young children.

[Mr Richard Bacon (South Norfolk) (Con)]

I congratulate my right hon. Friend on securing this debate. I recently had a meeting with Dr Nick Stolls, who for 20 years ran the local dentistry committee in Norfolk and Suffolk and is now the professional lead for dentistry and wellbeing for the integrated care board. He described work done by the British Dental Association that points out that Norfolk is almost a dental desert, with no dentists able to take contracts, in some cases because of NHS England’s inflexibility. Does my right hon. Friend agree that reform is needed? Will she invite the Minister to agree that, as the British Dental Association said, fundamental reform of the NHS dental contract is urgently required to truly address the challenges that patients, dentists and the wider NHS are experiencing?

[Priti Patel]

I thank my hon. Friend for making that point. The British Dental Association has been pressing for reform probably for as long as I have been in Parliament, and I am very familiar with its case. My hon. Friend speaks very clearly about access and inflexibility. Importantly, if there is no flexibility in the system, there is no opportunity to provide services to meet local need accessibly and in a way that means people do not think they will be charged or subject to barriers to access.

Oral Answers to Questions

Richard Bacon Excerpts

Tuesday 19th December 2017 Commons Chamber

[Mr Hunt]

I am very happy to offer the hon. Lady festive cheer and to explain to her that, even if her suspicion is right—and I do not believe it is—there has still been a significant increase in the number of staff employed in mental health trusts. The other suspicion she has constantly raised in the media and in this House is that mental health funding is being cut. She will know that the best news of this year is that, last year, funding actually went up by £575 million.

[Mr Richard Bacon (South Norfolk) (Con)]

Given that the NHS owns a great deal of land and buildings, and that mental health workers and other health workers face high accommodation costs, will the Secretary of State meet me so that I can explain how the benefits of the Self-build and Custom Housebuilding Act 2015 could be used as a powerful retention and recruitment tool for mental health workers?

[Mr Hunt]

I commend my hon. Friend for his work and thinking on this through the Public Accounts Committee, and he is absolutely right. I am more than happy to talk to him about this, but we actually have it as a priority to make sure that when NHS land is disposed of, NHS workers get the first opportunity to buy or rent the houses that are built.

NHS (Charitable Trusts Etc) Bill

Richard Bacon Excerpts

Friday 22nd January 2016 Commons Chamber

[Mr Richard Bacon (South Norfolk) (Con)]

Will my hon. Friend give way?

[Mr Rees-Mogg]

I was about to finish, but yes I will give way.

[Mr Bacon]

I was in the Tea Room and heard that a very fashionable Member was making a speech, so I thought I had better return to the Chamber at speed, which I did, and I am glad that I caught the end of my hon. Friend’s remarks. A liability might not arise in the way he describes, but surely he recognises that if the Secretary of State may allow the logo to be used, that would give rise to the possibility of judicial review. The Secretary of State may allow it in one case but not in another, and somebody who felt aggrieved by that could challenge the decision in the courts. Has my hon. Friend made any assessment of the extra cost of litigation for the Government and the NHS in defending such proceedings?

[Mr Rees-Mogg]

My hon. Friend has been caught up in this idea of fashion, and I am afraid that he speaks of yesterday’s fashion of judicial review. The great work done by the now Lord President of the Council and former Lord Chancellor, my right hon. Friend the Leader of the House, in restricting judicial review means that I simply do not think that that would now be a risk. It would have been a risk in those fashionable new Labour days, when people were judicially reviewing everything and having bogus consultations, which I spoke about earlier. That set the fashion for judicial review, but it is yesterday’s fashion. Those of us who are modern and who are with it—in the current phraseology—know that judicial review is yesterday’s news in such a context. Therefore, I do not believe that this would be a risk. It is a sensible way to deal with a problem that has arisen and to prevent it from arising again.

--- Later in debate ---

[Kit Malthouse]

I assume that my hon. Friend was not a shareholder of Marks & Spencer at the time. For those of us whose families were shareholders, it was a complete disaster, but I am glad that she was able to munch her pasty. The answer to her question is no; it is quite the reverse. The modern mind is much more akin to group-think, indeed to group hysteria. As politicians, we experience that daily on social media. We have all seen how small untruths, half-thoughts or theories can whip themselves up, on Twitter and Facebook, to become reality in a short space of time.

[Mr Bacon]

I agree with my hon. Friend. Was not one of the most profound and surprising examples of that, through the use of social media, the collective view that suddenly gained ground among hundreds of thousands of people that the right hon. Member for Islington North (Jeremy Corbyn) would be a good leader of the Labour party?

[Kit Malthouse]

My hon. Friend makes a remarkably good point. For Members of this House, that is a very pertinent example of the damage that social media can wreak on our ancient institutions, such as the Labour party.

The truth is that the modern mind is much more susceptible to such things, and particularly to charismatic leaders. One only has to look at the effect of Instagram, and the millions of followers that otherwise unmeritorious individuals have on it, to see how willing people are to go along with such things these days, like sheep in a herd.

--- Later in debate ---

[Kit Malthouse]

The truth is that there have not been adequate safeguards in charity law, as my hon. Friend will know. That is why the Charities (Protection and Social Investment) Bill is going through the House at this very moment. Anybody who has followed the passage of the Bill or sat on the Committee will know that part of it will beef up the powers of the Charity Commission to give it greater control in the event of financial misdemeanour or charities getting into financial trouble. It will strengthen exactly those powers about which I am talking.

[Mr Bacon]

My hon. Friend the Member for South Ribble (Seema Kennedy) pre-empted me. One might think that there was no need for the amendments because the Charity Commission, which was established in law to supervise these functions, would step in. However, does not the evidence from the National Audit Office report, “Giving Confidently”, from autumn 2001, and the much later evidence from the NAO’s studies over the past two or three years on the Cup Trust and the Charity Commission more generally, show that, in practice, the Charity Commission has a track record of not doing a particularly good job? In the circumstances that my hon. Friend the Member for North West Hampshire (Kit Malthouse) describes, where swift action is needed, the existing framework is not adequate. It is not enough simply to say that what he describes has not happened yet in a way that we can readily recall. The point, surely, is that we must create the governance architecture and environment to respond quickly when it is necessary to do so.

[Kit Malthouse]

My hon. Friend makes a very good point. I recommend to the House his book, which is filled with examples of Government incompetence, many of which were brought about by the group-think phenomenon and a lack of good governance. He is an expert in National Audit Office reports, having pored over many of them in his time on the Public Accounts Committee in the last Parliament and, I think, the one before that.

[Mr Bacon]

Fifteen years.

[Kit Malthouse]

Fifteen years on the Public Accounts Committee—extraordinary! I therefore take his words seriously. He is right that the key is to get the governance entirely right.

I guess the point that I am making—maybe I am a lone voice, although perhaps I am joined by my hon. Friend the Member for North East Somerset—is that even with the most ideal governance in the world, things occasionally go wrong. In that instance, the Secretary of State must have the power to step in, given the critical nature of the services these charities perform and their inextricable link to the national health service.

Contaminated Blood

Richard Bacon Excerpts

Thursday 15th January 2015 Commons Chamber

[Mr Richard Bacon (South Norfolk) (Con)]

I have listened to many of these stories with growing anger. Constituents of mine have also been affected. Does the right hon. Gentleman agree that Governments of both parties have failed our constituents for many years, and that the House will have no patience with any Government of any party who do not produce a final resolution of these matters?

[Mr Howarth]

In a word, yes.

East of England Ambulance Service

Richard Bacon Excerpts

Tuesday 25th June 2013 Westminster Hall

[Priti Patel (Witham) (Con)]

Mr. Howarth, it is a pleasure to serve under your chairmanship this morning. I thank Mr Speaker for granting me this debate and I thank all colleagues from across the region who are present today for their support in securing this debate and for pursuing this issue so assiduously.

We in the east of England are fortunate that two of our Members of Parliament are Ministers—the Under-Secretary of State for Health, my hon. Friend the Member for Central Suffolk and North Ipswich (Dr Poulter), and the Minister of State, Department of Health, my hon. Friend the Member for North Norfolk (Norman Lamb)—and both are well aware of this issue and have taken a great deal of interest in it. I put on the record my thanks in particular to my noble Friend Lord Howe, who has not only taken a strong interest in this subject, but helped facilitate many meetings with various bodies and the ambulance trust, and others, to explore this issue further. I know that this Minister will be well briefed on this matter and will be aware of the many and considerable concerns of colleagues in the region about the performance of the East of England Ambulance Service NHS Trust. She has shown strong interest in the health problems of my constituents and they will welcome her active involvement in helping to get this trust turned around.

This is a timely debate, following on from the scandalous revelations about the cover-up at the Care Quality Commission and the lack of responsibility and accountability from NHS directors. This trust has also experienced serious issues with accountability and mismanagement. It is suffering from the rotten culture that my hon. Friend the Member for Central Suffolk and North Ipswich recently mentioned.

Before I run through many of the problems with the trust encountered by my constituents and I, and the challenges, including delays, response times, damning reports from the CQC and from Dr Anthony Marsh, I should like to begin on a positive note and pay tribute to the outstanding work undertaken by the front-line staff. Despite many problems with the trust and its board, the front-line staff have earned admiration and a great deal of respect from all our constituents. They work in difficult conditions, all made worse by the failure of the trust’s board, but they continue to save lives daily and, of course, they help patients get better.

[Mr Richard Bacon (South Norfolk) (Con)]

I support what my hon. Friend says about front-line staff; I have had personal experience of that in my own family in Norfolk. The paramedics that we encountered were outstanding. Does she share my puzzlement that some of the best staff in the call centre, whom I have sat next to, were bewildered by the systems they were asked to deal with? The problem is not the front-line staff at all, who are superb, but is basically one of leadership.

[Priti Patel]

Of course, my hon. Friend hits the nail on the head. This is about management and lack of leadership and direction from the trust.

I also pay tribute to the volunteer community first responders who support the trust. I think that all hon. Members will have met first responders in their constituencies. Let us be clear that those individuals sacrifice their own time to attend to ill and injured people quickly and remain with them until paramedics arrive. I have been briefed by the co-ordinator of first responders in my constituency and am more than impressed by the actions they take to save the lives of patients in emergency situations, dealing with a wide range of conditions, including heart attacks, allergic reactions and unconsciousness. This month, the trust announced that 30 more of these volunteers had completed their two-day training course. We should celebrate that achievement and praise those volunteers for their dedication to helping the ambulance service and, of course, all our constituents. Those front-line members put the needs of patients first.

With so much devotion and commitment from the front-line staff and volunteers, of course it is more than disappointing that they have been so badly let down by the trust’s board and management. Staff and volunteers deserve more support and strategic leadership from the trust. It is because the trust’s board has failed to demonstrate in the boardroom the high level of expertise, skill and devotion required that is displayed on the front line that the trust has been brought into such a dreadful state.

The biggest danger to patients, which many hon. Members have experienced, is delays getting ambulances to them. The Minister will know that this trust has failed lamentably to meet the A8 and A19 targets. Patients with life-threatening conditions are being made to wait longer than they should for paramedics to arrive.

--- Later in debate ---

[Mr Richard Bacon (South Norfolk) (Con)]

It is a pleasure to speak in this debate and I congratulate my hon. Friend the Member for Witham (Priti Patel) on securing it. The national health service includes many people with different callings, and thank goodness for that. Some have a calling to look down microscopes and to do scientific experiments to figure out how to solve the problem of cancer. Some have a calling to work with people with mental health problems and to help them return to stability, productivity and a flourishing life. Some have a calling to help at the roadside those who are in critical danger following dreadful accidents and those of us who are unfortunate enough to face near death. Imagine what it must be like to have that calling, to feel that one’s life purpose and work is to help such people, to have the training of a practitioner in emergency medicine, but to have to hold someone who is dying because an ambulance trust does not work properly and those higher up let down the practitioners. What would be the reaction?

There would come a point when people would say, “I can’t stand this any longer. I can’t stand coming to work and failing people because those above me are failing me.” That is exactly what has happened. It is absolutely clear, as my hon. Friend the Member for Harlow (Robert Halfon) said when quoting from the Marsh report, that it is not about money. The problem is about leadership and accountability. I will draw out some brief points from that report. It says that

“critical decision making has ceased in some areas. The trust has lost focus of the strategic objectives, which may partly be due to the board not fully understanding the purpose of the business.”

It continues:

The management structure is overly layered and appears heavy…The trust seems to demonstrate limited urgency and pace in moving forward.”

It also states:

“Leadership does not come from Board level”.

What are they doing, and why are they still there after that damning report?

As a member of the Public Accounts Committee, I have spent 12 years studying slow-motion disasters in various areas of Government and I have read many National Audit Office reports across the whole swathe of Government activity and public expenditure, but I have rarely read words as damning as those. Yet the people who are responsible, who, as my hon. Friend the Member for Harlow said, have so badly failed those whose job it is to serve us and our constituents, are still in post. That is something I cannot understand, and I very much hope that the Minister will address it. If it is not addressed, there will come a point when people will start asking the Department of Health why it has not been addressed, because the matter is so serious.

This did not use to happen. I have been the Member of Parliament for South Norfolk in the east of England for 12 years, and until the last year or two I do not recall people regularly writing to me with complaints about ambulance delays. I do not remember regularly turning up at meetings in the House where there were 15 paramedics talking to the Minister, Earl Howe, facilitated by east of England MPs, because there was no possibility of their having a sensible conversation with the management of their own organisation. This is an extraordinary state of affairs and it requires radical reform.

There is not time in this debate to talk about the wider issues of the NHS culture, but reference has been made to revolving doors and how people lose jobs in one place and gain them in another—I have seen a lot of that myself. In addition there is the issue of confidentiality clauses and the way in which the guidance against using them has been weakened. In 1999, it was stated that confidentiality clauses had no place in NHS contracts; by 2004, it was apparently okay if the guidance was studied carefully.

In the limited time available I want to make a point about size. The ambulance trust in the east of England covers Hertfordshire, which is practically outer London, and Bedfordshire, which is also practically outer London and highly urbanised, as well as places as far away as Cromer in north Norfolk, Great Yarmouth, Southwold in the constituency of my hon. Friend the Member for Suffolk Coastal (Dr Coffey) and Lowestoft in the constituency of my hon. Friend the Member for Waveney (Peter Aldous). It is simply too big, and that is obvious to everyone.

In my rural constituency, ambulances are not just dragged away from the rural areas to Norwich. I accept the point made by the hon. Member for Cambridge (Dr Huppert), who is no longer in his place, that it is not just a rural problem; it is a rural and an urban problem. When I find that ambulances are being dragged away to Bedford and Luton, which are one hour 20 minutes, one hour 25 minutes or one hour and 30 minutes from my constituency, I know that something is fundamentally wrong. We must stop thinking so much about economies of scale and start thinking about the economy of flow—removing the blockages that stop things working properly.

--- Later in debate ---

[Anna Soubry]

That is a good point, but it is not for me to say whether it has any merit that should be taken forward. But clearly it is an important point, which must now be considered.

May I quickly pay tribute to all the very helpful interventions from hon. Friends? My hon. Friend the Member for Broadland (Mr Simpson) talked about the buck passing in the NHS and the recycling. We also heard from my hon. Friends the Members for Maldon (Mr Whittingdale) and for Huntingdon (Mr Djanogly). My hon. Friend the Member for Waveney (Peter Aldous) made an excellent speech. My hon. Friend the Member for Suffolk Coastal also made an excellent and important speech. There were interventions from my hon. Friends the Members for Clacton (Mr Carswell) and for Cambridge (Dr Huppert) and from my right hon. Friend the Member for Saffron Walden (Sir Alan Haselhurst). There were speeches by my hon. Friends the Members for Harlow, for North West Norfolk and for South Norfolk (Mr Bacon). They all made important and good points.

We know that overall in England in 2012-13 the number of emergency calls to ambulance services was 9.08 million—a 6.9% increase. That is an important figure, I would suggest. We know that overall, in England, the performance figures are stable. That does not really assist in this debate, of course, because we also know that the East of England ambulance trust and, I have to say, my own, the East Midlands ambulance trust, have serious failings and the performance figures are simply not good enough.

The best that I can say of the performance of the East of England ambulance trust is that it has not been good. It is clearly recognised as the lowest-performing ambulance trust in England. As with the national picture, its overall poor performance figures hide huge discrepancies between the services and response times in the urban and rural areas that it covers. There are too many stories—we have heard many today—of patients in distress having to wait hours for ambulances, or solo paramedics being sent when an ambulance is needed. Solo paramedics cannot transport patients and might not, for instance, be able to lift or move a patient unaided. It is simply not good enough.

It is clear to me that some hon. Members and many patients might be forgiven for thinking that the trust seems to have forgotten that it is there to serve all patients and not only tick the performance boxes as far as it can. Concentrating resources in towns and effectively abandoning people in the countryside is simply unacceptable.

[Mr Bacon]

Will the Minister give way?

[Anna Soubry]

May I make some progress? Then I will take an intervention. The latest figures, as we have heard, show that the East of England ambulance trust failed to deliver two of the three response time standards. The exception was the performance against Category A Red 1—immediately life threatening—calls, where the 75% standard was achieved, with 75.8% of calls responded to within eight minutes.

[Mr Bacon]

The phenomenon of people forgetting what they are there for, which my hon. Friend alluded to, is of course what would happen in a mates culture. I have had the feeling for a long time that there has been the growth of what we might call a self-serving nomenclatura that looks after its own interests first. Then I heard my hon. Friend the Member for Bristol North West (Charlotte Leslie) on the radio the other day referring to a mafia within the top of the NHS, looking out for their own interests. What I want to know is, as this is a recognised phenomenon—I do not think we are going mad—what is the Department going to do about it?

[Anna Soubry]

In short, what I will say is that the Secretary of State has made it clear that it is a culture that he will not accept, and that no member of his ministerial team will accept. He is now becoming undoubtedly the champion of the patient. We are seeing that. We saw it last week with the CQC and then of course we saw the change: the names of people who had been put forward in the report were made public and people are now being held to account. We are beginning to see at least a tackling of this culture; we now need to see some results.

Information Technology (NHS)

Richard Bacon Excerpts

Tuesday 14th June 2011 Westminster Hall

[Mr Richard Bacon (South Norfolk) (Con)]

It is a pleasure to serve under your chairmanship, Dr McCrea. I am reminded of Fidel Castro’s old maxim that any speech of less than three or four hours cannot be any good, and when I reviewed the material available for this debate, I felt that it might be difficult to put everything I want to say into a shorter time. I appreciate, however, that this debate lasts only 90 minutes and that the Front-Bench speakers will be called fairly soon. I am not planning to take many interventions during my remarks, so that I can get through everything I wish to say as quickly as possible.

The importance of information technology to good health care cannot be overstated. As leading health informatics expert, Dr Anthony Nowlan, put it:

“Redesigning the ways care is organised and conducted and supporting those new ways with information science is more important to people’s health overall than any new drug we could develop in the next decade.”

He also stated that

“the engagement of clinicians and managers is not just about telling them what is going to happen.”

Sadly, those words accurately summed up a significant part of the problem that we faced.

The national programme for IT in the health service is the largest civilian computer project in the world. It was spawned in late 2001 and early 2002, after the then Prime Minister, Tony Blair, met Bill Gates and was bowled over by a vision of what IT could do to transform the economy and health service. The idea was for information to be captured once and used many times, transforming working processes and speeding up communications. A far-reaching vision set out a programme that would supposedly lead to a transformation in people’s experiences of health care. Hospital admissions and appointments would be booked online—the choose and book system—pharmacists would no longer struggle with the indecipherable handwriting of GPs; and drug prescriptions would be handled electronically. There was to be a new broadband network for the NHS, a new e-mail system, better IT support for GPs and digital X-rays. Most important of all, medical records would be computerised, thus transforming the speed and accuracy of patient treatment through what became known as the NHS care records service.

The NHS care records service comprised two elements: first, a detailed care record that contained full details of a patient’s medical history and treatment. That was to be accessible to a patient’s GP and to local community and hospital care settings, so that if treatment were required, all the information would be available. Secondly, there would be a so-called summary care record that contained medical information about things such as allergies and would be more widely available.

It became clear that Tony Blair was in no mood to wait when he asked Sir John Pattison, who attended the Downing street seminar in February 2002 where these matters were discussed, how long the IT programme would take. Sir John Pattison later stated:

“I swallowed hard because I knew I had to get the answer right… and I said three years.”

Tony Blair replied, “How about two years?” and they settled on two years and nine months from April 2003—in other words, until December 2005. Given the extent of the proposals, that was a ludicrous timetable. Nevertheless, the decision had been made, and everything had to be done at breakneck speed.

Sir John Pattison and his team set to work and produced a blueprint entitled “Delivering 21st century IT support for the NHS: national strategic programme”, which was published in June 2002. The aim was to connect the delivery of the NHS plan with the capabilities of modern information technology. There was, however, an odd discrepancy at the outset. At the back of the original document were four appendices, one of which contained the project profile model and stated that the project’s estimated whole-life costs were £5 billion. It provided a total risk score of 53 out of a maximum of 72. In other words, the project was very high risk. When the document was published, however, that project profile model had been removed and there were only three appendices—the likely costs of the project and the true risks were concealed right from the start. After the publication of the document, the Department of Health established a unit that later became the Connecting for Health agency. In September 2002, Richard Granger was appointed as director general of the NHS IT programme on a salary of about £250,000. His job was to turn the national strategic programme—which soon became the national programme for IT in the health service—into reality.

Richard Granger was a former Deloitte consultant who had successfully overseen the introduction of the London congestion charge. Speaking at a conference in Harrogate some months after his appointment, he announced that the cost of the IT programme would be £2.3 billion. That figure contrasted with the unedited version of Sir John Pattison’s “Delivering 21st century IT support for the NHS”, which a few months earlier had come up with the larger estimate of £5 billion.

Mr Granger commissioned a study by McKinsey into the health care IT market in the UK, which was then dominated by medium-sized firms that sold systems to hospitals and GP surgeries. The study concluded that no single player was capable of becoming a prime contractor in a multi-billion pound programme, and Mr Granger soon announced that the procurement process for the programme would be structured to attract global IT players. He had little respect for the skills of most public sector buyers of computing systems—perhaps with good reason if one looks at the track record—and knew that IT contractors routinely run rings around their customers in government.

Mr Granger made it clear that things would be different on his watch. Contractors would not get paid until they delivered, and those not up to the mark would be replaced. He even compared contractors to huskies pulling a sled on a polar expedition:

“When one of the dogs goes lame, and begins to slow the others down, they are shot. They are then chopped up and fed to the other dogs. The survivors work harder, not only because they’ve had a meal, but also because they have seen what will happen should they themselves go lame.”

Mr Granger started as he meant to go on, and potential contractors were left in no doubt that the procurement process was to happen quickly. In May 2003, potential bidders were given a 500-page document called a draft output-based specification, and told to respond within five weeks.

One of the classic failures in many IT projects is the failure to consult adequately with those who will use the systems once they are delivered. The national programme followed that pattern in many respects, but in this case that did not happen by accident. Mr Granger had no patience with what he saw as special pleading by medical staff, whom he believed were unwilling to accept the ruthless standardisation that was necessary to deliver the advantages offered by the IT system. He effectively believed that he knew what the clinicians needed better than they did themselves.

Some clinicians were keen to ensure that they had proper input into what was happening. Sir John Pattison asked Dr Anthony Nowlan, the health informatics expert who at the time was the executive director of the NHS Information Authority, to secure the involvement of health professionals in the programme. The aim was to obtain a professionally agreed consensus about what was the most valuable information to store, and what was achievable in practice.

After several months the group had hammered out a consensus, but although that work was fed in when the contracts began to be specified, it formed only a relatively small part of the overall specification. The large majority of the so-called output-based specifications, and the crucial major hospital systems at the heart of the programme, were developed without involvement and scrutiny by the leadership of the health profession. That happened despite the fact that involvement by users is essential if one wants software that works and that people will use.

The great speed at which contracting was completed meant that all complex issues had to be faced after the contracts had been let. Anthony Nowlan began to realise that his efforts were not welcome, and he told the Public Accounts Committee that

“it became increasingly clear to me that efforts to communicate with health professionals and bring them more into the leadership of the programme were effectively obstructed.”

Worse still, Nowlan was subsequently asked to provide a list of the names of hundreds of people who had been involved in specification work, so as to provide evidence to reviewers that the work was valid. In fact, all that had happened was that an e-mail had been sent out. Quite understandably, Dr Nowlan thought that saying that people had been consulted because they had been sent an e-mail was not consultation in any proper sense, any more than compiling a list of people who had been sent an e-mail was proper validation. He regarded the claims as a sham, and refused to co-operate.

It turned out that serious clinical input into the programme was not really wanted. As Professor Peter Hutton later told the PAC,

“it was like being in a juggernaut lorry going up the M1 and it did not really matter where you went as long as you arrived somewhere on time. Then, when you had arrived somewhere, you would go out and buy a product, but you were not quite sure what you wanted to buy. To be honest, I do not think the people selling it knew what we needed.”

The result was a set of contracts that were signed before the Government had understood what they wanted to buy and the suppliers had understood what they were expected to supply.

When the then Health Secretary John Reid—now Lord Reid—announced the contract winners in December 2003, the value of the contracts had already shot up to £6.2 billion from the original £2.3 billion mentioned by Mr Granger in Harrogate. The time scale had tripled in length, and instead of the two years and nine months from April 2003 originally promised—to which Sir John Pattison had been obliged to commit at the Downing street seminar—the contracts were now to run for 10 years. Later, one of the most senior officials in the national programme, Gordon Hextall, even claimed that it was always envisaged that the programme would run for 10 years.

Four winning bidders were appointed: Accenture; Computer Sciences Corporation, or CSC; Fujitsu and BT. They were known as local service providers, or LSPs. BT and Fujitsu picked a US software firm, IDX, to work with, while Accenture and CSC both picked a British software company called iSoft. iSoft was a stock market darling that had been spun out of the consulting firm KPMG in the late 1990s. The company’s flagship was a software system called Lorenzo, which was portrayed enthusiastically in iSoft’s 2005 annual report and accounts. The chairman, Patrick Cryne, told shareholders that Lorenzo had made “impressive progress”, while chief executive Tim Whiston stated that Lorenzo would be “available from early 2004” and that it had

“achieved significant acclaim from healthcare providers”.

With such promising statements from the company’s directors, the stock market was delighted, and it was no surprise that iSoft’s share price rose sharply. Mr Cryne, Mr Whiston and their fellow directors then sold large tranches of their personal shareholdings in iSoft, making around £90 million in cash. In 2004, Patrick Cryne bought Barnsley football club.

There was a slight problem. The flagship product, Lorenzo, which was described in such encouraging terms by the directors, was not finished. That caused a big headache for Accenture, the biggest LSP, with two contracts worth around £1 billion each. It was in partnership with iSoft and was trying to implement software that was basically not implementable. CSC faced a similar problem in the north-west. Under the Granger rules of engagement, no one was supposed to get paid until something was delivered. As iSoft had not produced a working version of Lorenzo, the brutal reality was that neither Accenture nor CSC had any software to deploy.

There were still big concerns about the programme’s indifference to securing clinical buy-in from users—clinicians in hospitals—even though numerous studies had pointed to such buy-in as the key ingredient for success in any IT project. Professor Peter Hutton wrote to the then chief executive of the NHS, Sir Nigel Crisp, to express his continuing disquiet:

“I remain concerned that the current arrangements within the programme are unsafe from a variety of angles and, in particular, that the constraints of the contracting process, with its absence of clinical input in the last stages, may have resulted in the purchase of a product that will potentially not fulfil our goals.”

Soon after pointing out politely that the emperor had no clothes, Professor Hutton was asked to consider his position, and he tended his resignation. The IT people were simply not interested in what the doctors were telling them. To give it belated credit, however, the Department of Health began to realise that securing the support and buy-in of clinicians who would have to use the systems might be a good idea.

In March 2004, the deputy chief medical officer, Professor Aidan Halligan, was appointed alongside Richard Granger as joint director general of NHS IT, and joint senior responsible owner of the programme, with specific responsibility for benefits realisation. That was welcomed by clinicians. One delegate at the Healthcare Computing conference in Harrogate said that Halligan’s appointment was “really, really good” because

“he has the trust of clinicians and can stand up to Granger”,

although a general practitioner delegate at the same conference said that it “spoke volumes” that nobody like him had been in the post earlier. Halligan acknowledged that not enough had been done to win the support of clinicians, whose buy-in, he said, was critical to the success of the project. Listening to clinicians was now the flavour of the month. However, there was one insuperable difficulty—the contracts had already been signed. As Professor Hutton later explained to the PAC,

“it became clear from discussions with suppliers in early 2004 that what they had been contracted for would not deliver the NHS Care Record”.

Accenture and CSC struggled on with the unusable Lorenzo. Eventually they commissioned a study that produced a confidential report in February 2006, which confirmed their worst fears. The report stated that the Lorenzo had

“no mapping of features to release, nor detailed plans. In other words, there is no well-defined scope and therefore no believable plan for releases.”

That was over five years ago.

In March 2006, Accenture announced to its shareholders that it would use $450 million to cover expected losses on the programme. It made repeated offers to the programme that it would meet its contractual obligations by using other software. However, that might have bankrupted iSoft, and Richard Granger was having none of it. He responded with a threat when Accenture talked about walking away. Referring to tough penalty clauses contained in the contracts, he said that

“if they would like to walk away, it’s starting at 50% of the total contract value”.

Accenture had two of the £1 billion-a-piece prime contracts, so it appeared to be facing a cool £1 billion in penalty payments to the Government if it abandoned the programme. Strangely, it did not work out that way. Accenture engaged in swift negotiations with the health service and in September 2006, after making a penalty payment of just £63 million, it duly exited the programme. Mr Granger’s threat, that if Accenture left the programme it would face gigantic penalty payments, proved to be of little account. There were rumours that if Mr Granger had demanded any more money, he would have faced serious and embarrassing counter-claims from Accenture for failures by the national programme to stick to its own contractual obligations.

CSC, with its own £1-billion contract for the north-west and west midlands regions, was in no better a position than Accenture to implement the unfinished Lorenzo software. It was also struggling to mop up after having caused the largest computer crash in NHS history, when its Maidstone data centre was hit by a power failure, followed by restarting problems. The back-up systems did not work, and data held in the centre could not be accessed. That meant that, for four days, 80 NHS trusts could not use their patient administration systems and had to operate as best they could with paper systems.

Another worry for CSC was its shareholders. Accenture had set aside hundreds of millions of pounds against expected losses and told the stock market accordingly, but CSC had done no such thing. In addition to its problems with losses in the UK, the company had troubles back home in the United States, where it faced allegations of corruption. The US Department of Justice had alleged that CSC was part of an alliance, which included virtually all the major sellers of hardware and software in the United States, that had swapped unlawful kick-backs in Government agency technology contracts. CSC finally agreed to a $1.37 million payment to resolve those allegations. That was reported on the news blog of Cnet.com on 13 May 2008, under the heading:

“CSC settles with feds over kickback allegations”.

In such circumstances, having extra contracts from the NHS might look reassuring to the US stock market. Despite the fact that there was no implementable software—Lorenzo still was not finished—CSC quickly took on both Accenture contracts, tripling its involvement in the programme. However, there were continuing problems at iSoft, which was supposedly writing the Lorenzo software. One of the problems related to the publication of iSoft’s financial results, which had been repeatedly delayed, up to the point where one of iSoft’s own advisers, Morgan Stanley, a brokerage, declined to publish a profit forecast, stating:

“We don’t feel we have enough visibility to offer a recommendation”.

With friends like that in the stock market, who needs enemies? Finally, iSoft was forced to declare a loss of £344 million, which wiped out all the company’s past profits. The Financial Services Authority launched an investigation.

Now, three fifths of the programme was dependent on one troubled local service provider, CSC, which was using a software supplier, iSoft, that was itself under investigation by the FSA. One regional contractor, Accenture, had been replaced by another, CSC, which had less experience. The central problem remained: the software that they had been trying to deploy, iSoft’s Lorenzo system, was still not finished.

In those circumstances, iSoft started to deploy software products that predated the programme, which Connecting for Health duly paid for. Those older products did not meet the specifications for the national programme. It is important to remember that fact, because that is what many acute hospitals have now been given—old and outdated software that was deemed inadequate nine years ago to meet the programme’s specifications.

Meanwhile, the other two providers, BT and Fujitsu, were having their own problems. They were trying to implement American software, which is not such an easy thing to do in a British hospital, because American hospitals rely on billing for each and every activity and do not, conversely, expect to have to handle waiting lists. An American software system cannot be just uploaded to an acute hospital main frame and be switched on—it is not that simple.

In June 2005, IDX was dropped by Fujitsu with Richard Granger’s consent and replaced by another American firm, Cerner, which had a software package for large acute hospitals called Millennium. BT, some 18 months after winning its LSP contract, was still struggling with IDX. By July 2005, BT was facing serious threats from Richard Granger that it could be axed if it did not start to perform. In an interview with Computing magazine, Mr Granger said:

“BT had better get me some substantial IDX functionality by the end of summer or some predictable events will occur.”

However, it was not that simple. As the leading health care IT website, e-Health Insider, pointed out, replacing BT as the local service provider

“would represent a major failure for the programme, and raise questions over the whole IT-enabled NHS modernisation”

and lead to even more delays. The website added:

“Such a move would also potentially raise serious questions about whether the adversarial management style of Connecting for Health is the most likely to deliver new systems that provide clinical benefits to patients in a timely and cost-effective fashion.”

BT was allowed to continue as the local service provider and eventually, with Granger’s consent, it was allowed to follow Fujitsu’s lead and replace IDX with Cerner Millennium.

At a London conference in July 2005, Mr Granger gave a stern warning to suppliers who were lagging behind on delivery:

“We will get very soon to a point where they will either come good with what they’ve got, or they will get a bullet in the head.”

Mr Granger was also showing signs of defensiveness about the programme, stating:

“It might be a policy disaster, but it isn’t an IT disaster. The system was delivered to spec”,

and he gave the example of the electronic staff record. He added:

“If some of my colleagues do not think sufficiently through as to what was wanted then it’s a specification error.”

Such statements by Mr Granger led to howls of rage from some industry observers, including one who, after Granger’s speech, posted a comment on the e-health Insider website, saying:

“Now and then I check myself from hatred of what Richard Granger stands for and has done to NHS IT, and then the sheer arrogance and ignorance of his public statements brings me back. He set the ridiculously short timescales for decision-making, procured before there was a clear idea of the scope, handed all the ‘choice’ from NHS clinicians to private contractors. CfH”—

Connecting for Health—

“hasn’t solved the funding crisis for computerising the NHS, rather landed us with a massively expensive way to do what some of us were achieving already”.

Meanwhile, the National Audit Office had embarked on a study of the national programme, which was due to be published in summer 2005, but there were considerable delays. As Members may know, NAO reports involve a clearance process, during which a report’s factual content is cleared with the Government before publication, and that has benefits for both sides. However, something different happened with the national programme report. It was as if Connecting for Health wanted to use the clearance process to expunge the slightest criticism of its activities. It undertook a war of attrition with the auditors, in a process that the NAO later described as fighting

“street by street, block by block”.

The final report was delayed again and again, and it finally appeared in June 2006. It was much weaker than seasoned health IT observers had expected. The Minister of State, Department for Communities and Local Government, my right hon. Friend the Member for Tunbridge Wells (Greg Clark), who was then a member of the PAC, described it as “easily the most gushing” he had read, while a BBC correspondent described it as a “whitewash”. Most of the key criticisms were eventually excised, as Granger and his team ground down their opponents. It later emerged through freedom of information requests that earlier drafts had been much tougher.

Tom Brooks, a management consultant with years of worldwide experience in health care, wrote a devastating submission to the PAC, in which he questioned the whole rationale for central procurement in the programme. He said that

“the poor quality of the negotiation of the NPfIT contracts by Mr Granger”

was a subject of criticism. He described the view that central procurement would produce systems that met local requirements as “a fundamental error”. He told the Committee:

“MPs are mis-informed if they view the central infrastructure as making reasonable progress”.

Dr Anthony Nowlan, whom I mentioned earlier, described the programme as “back to front”, given that the contract stating what would be produced had already been let. He pointed out the sheer absurdity of a consensus document produced by the programme stating:

“Now that the architecture for England has been commissioned, designed and is being built, there is a need for clarity concerning how it will be used”.

A group of health IT experts sent the PAC a detailed paper offering a devastating critique of the entire programme. The group provided evidence that it was likely to deliver neither the most important areas of clinical functionality nor the benefits required to justify the business case. The group simply stated:

“The conclusion here is that the NHS would most likely have been better off without the National Programme in terms of what is likely to be delivered and when. The National Programme has not advanced the NHS IT implementation trajectory at all; in fact, it has set it back from where it was going”.

In view of the frequent misunderstandings about the national programme among so many journalists, broadcasters, politicians and commentators, it is worth quoting the expert group’s document at some length. It starts by saying:

“It is useful to begin with the question: What is the central point of NPfIT—its chief raison d’etre? Is it a shared medical record (otherwise known as the ‘Central Spine’ or ‘Central Summary Care Record Service’) across England?

The answer to this important question is simply: no…the central point of NPfIT is to provide the local Care Record Service...Compared with the local CRS, the Central Spine is a much lower priority because it is totally speculative and even if delivered is likely to result in very little clinical benefit…This is a subtle but critical point. The Local CRS systems…are a proven technology…These local CRS systems have always been costly investments (several million pounds per hospital over several years) but have been proven in the NHS and elsewhere to deliver real clinical benefits…This picture is entirely different for the so-called Central Spine record, or Central Shared Summary record, which NPfIT (and the government ministers) would like the public to believe is the central point of NPfIT. It is not. The Central Spine record is just a concept…The problem is that clinicians have told us medicine does not work like this. Clinicians do not just use a summary record to deliver care. They build and depend upon detailed and specific medical data that are relevant for each patient.

They do not rely on some other clinicians’ definition of what will be most relevant to put in a summary record. What is relevant clinically will inevitably vary from patient to patient.

The concept of a summary Central Spine record has no scientific basis and no significant clinical support to back it up—just an overly simplistic and naïve storyline about a Birmingham patient falling ill in Blackpool. In fact, no one has ever provided any figures on how often this situation is likely to arise to show whether or not the investment in the Central Spine record is worthwhile.

The point here is that the Local Care Record Service”—

I emphasise the word “local”—

“is the essential building block for clinically useful health IT to support clinical care in progressive, modern and proven ways. Yes, it is difficult to implement and can take 2-3 years to roll-out across the whole hospital (or organisation), and yet it is always worthwhile…These Local Care Record Service systems are the building blocks and are the point of NPfIT, and what NHS Trust Chief Executives want, need and expect. They are not waiting for a Central Spine record to run their hospitals.

However, the Local Care Record Service systems (or the Local Service Providers’ newest versions of them) are not likely to be fully deployed now (only the rudimentary patient administration elements of them will be) because NPfIT is putting in old ‘legacy’ products in place of new modern Local Care Record Service products in its panic to show deployment and because the systems have been so late in being delivered by the LSPs”—

the local service providers. The document continues:

“The key point of the National Programme for IT is to provide both depth of clinical systems functionality and breadth of integration in terms of delivering the contracted Local CRS functions across organisations and care-settings (acute, primary, mental health, social services).

This is the true vision of health IT promised by the National Programme which is embodied in the Local Service Provider contracts and it is what their price reflects.”

The trouble is, with all the delays, the LSP schedules are being down-scoped behind the NHS’s back and without any accountability to the local NHS Trust chief executives to whom the original vision was promised.”

In September 2006, with the hon. Member for Southport (John Pugh), I published a paper called “Information technology in the NHS: What Next?” In it, we identified four fallacies and offered a way forward. The fallacies were that

“Patient data needs to be accessible all over the country…Local trusts can’t procure systems properly so the centre has to do this for them…Large areas of the NHS need to work on a single massive system”

and that the

“National Programme saves money.”

The suggested way forward was to allow hospital chief executives to buy the systems they actually wanted, subject only to common standards, and to fund such purchases partially from the centre, while making local chief executives contractually responsible for delivery.

Shortly after we published that paper, the NHS chief executive, David Nicholson, introduced the NPfIT local ownership plan, but it did not follow our suggestion of giving local chief executives autonomy in what they bought. Under the NLOP, hospital chief executives would still be required to buy the software that the local service provider was contracted to provide—the difficult-to-install American system, Cerner Millennium, or the non-existent Lorenzo.

Furthermore, instead of there being one senior responsible owner for the programme, which is a central tenet of good project management practice, there would be many dozens of senior responsible owners dispersed among the different primary care trusts, strategic health authorities and hospitals across the country. Those bodies were given responsibility for implementing and delivering software that was not available or which did work properly, without a free choice to buy something else that did work. The NLOP looked more like an attempt to decentralise impending blame than a serious attempt at reform. That is why Tony Collins, one of the country’s leading computer journalists, playfully said that NLOP actually stands for “No Longer Our Problem”.

In February 2007, Andrew Rollerson, a senior Fujitsu manager who had assembled and then led the winning Fujitsu team in the original bid process, mentioned more or less en passant at an IT conference that his view of the national programme was that

“it isn’t working and it isn’t going to work”.

To many informed observers, it was just a statement of the obvious. The PAC called him to give evidence, and when asked if he felt that he had been the

“one who let the finger out of the dam”

and allowed

“a whole collective sigh of relief”

to go round the health IT sector, he replied

“I think that is absolutely spot on.”

Fujitsu then wrote to the Committee stating that Rollerson was not a senior executive of the company and had not been involved for a long time, but neglecting to mention that he had led the winning bid team.

By 2007, another accounting probe had been launched into iSoft by an accounting standards body, and in the following month, April, the PAC published its report, which concluded that

“at the present rate of progress, it is unlikely that significant clinical benefits will be delivered by the end of the contract period”.

By June 2007, Richard Granger had announced that he would quit at some point and shortly afterwards stated that he was “ashamed” of some of the systems put in by Connecting for Health suppliers, singling out Cerner for criticism. David Nicholson, the NHS boss, appointed several new senior executives to join Granger at the top table, while continuing to reject calls for a full review. Tony Collins wrote in Computer Weekly that the future of the national programme for IT in the NHS was “hazy” and that it was becoming

“difficult to delineate success from failure”.

Derek Wanless, whose major review for Tony Blair into the future of the health service had first identified investment in IT as an area for improvement, publicly questioned whether the NHS IT programme should continue without a full audit. He said that

“there is as yet no convincing evidence that the benefits will outweigh the costs of this substantial investment”.

In October 2007, the Department of Health rejected rumours that Matthew Swindells had been appointed interim chief executive of Connecting for Health, but in an industry survey he was named the 12th most influential person in the NHS—10 positions above Richard Granger. It appeared that Richard Granger’s influence was on the wane and that he was being eased out. Tony Collins mused on his blog that the programme might be even worse without Richard Granger—

“the thought of this juggernaut being without a driver is even more scary that when it had a driver but no controls”.

Mr Granger’s last day as an employee of the NHS was 31 January 2008, though, curiously, it was a week, on 6 February, before the interim director of NPfIT and systems delivery, Gordon Hextall, sent a letter to Connecting for Health staff to tell them that Granger had gone and that two appointments would replace him: a top-level chief information officer and a director of IT programmes and systems delivery. Meanwhile, the interim chief information officer would be none other than Matthew Swindells, whose involvement the Department had denied earlier.

In February 2008, the Commons Health Committee published a report on the electronic patient record, which stated that it was “dismayed” by the lack of clarity about what information would be included in the summary care record and for what the record would be used. It also said that there was “a stark contrast” between the “specific and detailed” vision set out for the integrated care records service in 2003 and the “vague and shifting” vision set out in 2007. The Committee concluded that there was now a

“perplexing lack of clarity about exactly what NPfIT will now deliver.”

In May 2008, the NAO published a progress update, which was much more robust than its earlier report. It concluded that the programme has

“largely failed to deliver on its central objective of detailed care record systems for acute hospital trusts”.

Not a lot was happening at that point because there was no software to deploy, so many people were employed but they were not necessarily doing very much. In October 2008, Nick Timmins of the Financial Times wrote about the national programme in a front-page story:

“Progress has virtually ground to a halt, raising questions about whether the world’s biggest civil information technology project will ever be finished”.

He quoted Jon Hoeksma from e-Health Insider who said that

“the key part is stuck”

and added that hospital chief executives did not want to take the system

“until they had seen it put in flawlessly elsewhere”.

The second PAC report, published in January 2009, concluded that the programme’s failures raised questions about the feasibility of the whole project and that the central contracts—the enormous local service provider contracts—were an encumbrance. Only nine months into his job, Matthew Bellamy quit as the chief information officer’s right-hand man. Just before Christmas 2009, the then latest Health Secretary, the right hon. Member for Leigh (Andy Burnham), gave an interview in which he sang the praises of the national programme and said that

“parts of the NHS cannot operate without it”.

Unfortunately for him, the then Chancellor of the Exchequer, the right hon. Member for Edinburgh South West (Mr Darling), took a different view—and said so in a television interview a couple of days later. He said that the national programme was

“not essential for the front line”

and announced that he was imposing a £600 million spending cut that took its budget down from £12.7 billion to a mere £12.1 billion.

Meanwhile, new year 2010 was not a happy one for the iSoft directors. The Financial Services Authority—the chief City regulator—announced that it had laid criminal charges against four former directors of iSoft: Patrick Cryne, the founder and former chairman; Timothy Whiston, the former chief executive; and former directors Stephen Graham and John Whelan. They were accused of conspiracy to make misleading statements. The four denied the charges.

Where are we now? We have yet another NAO report, published on 18 May this year, which states in even more bald terms that

“the aim of creating an electronic record for every NHS patient will not be achieved under the Programme.”

The central aim of the programme will not be achieved under the contract. Several conclusions regrettably emerge about Connecting for Health. The first is about overpaying. It massively overpays: acute trusts are costing £23 million, when they should be about £8 million; the system for mental health and community trusts—RiO—is costing £8.9 million per deployment, when it should be about £1.5 million; and the other systems, such as the picture archiving and communications systems for digital X-rays—PACS—and N3 broadband, which everyone says is not particularly good anyway, are also massively overpriced. I should say in parenthesis that the digital X-rays are very good, but Connecting for Health should not have paid so much for them.

The second conclusion is on de-scoping. Connecting for Health has dealt with the problems it has faced by drastically reducing the scope of what is being delivered, but without corresponding reductions in cost. The third conclusion is the hiding of increased costs. The late deliveries meant there have been no running costs for systems that have not been delivered, and the surplus cash is being used to hide the increasing cost per deployment.

Fourthly, there are serious doubts about the commercial judgment and skill of Connecting for Health. It seems that every contract revision makes things worse. Very little of the originally expected system has been delivered, but despite that, the NHS seems to have little or no commercial cover. The Fujitsu termination, when it was fired from the programme, was farcical and generated massive potential costs and liabilities. The local service providers appear to be running rings around Connecting for Health commercially. As the Financial Times noted on 25 May this year, CSC is offering a one-third reduction in the cost of its contract in return for doing two-thirds less work. As the Cabinet Office observed, that would roughly double the cost compared with the original agreement.

The fifth conclusion is the danger of future high costs. When the contracts finish, there is inadequate provision to manage the systems in future. It takes a special skill to leave trusts stuck with systems that are functionally very poor and out-of-date, which were not deemed adequate nine years ago, and still manage to expose them to enormous future costs over which they will have very little control. That is precisely what Connecting for Health is managing to do. Finally, there is a serious danger that Connecting for Health will put CSC in particular in a monopoly position. The proposed revised agreement may be open to legal challenge from other suppliers who have not had the chance to bid.

What should happen now? It is plain that the NHS IT programme has not worked and there is no evidence that it will work. Rather than squandering another £4 billion to £5 billion, which is still unspent, the NHS should recognise reality. Connecting for Health has failed to achieve its central purpose and should be closed down. I am afraid that it will not help and is now more interested in the preservation of its own position than in protecting the interests of taxpayers. NHS trusts must be set free to choose the systems that meet the needs of patients and medical professionals. They should have the power to source products locally that suit their needs, subject only to common standards.

Life Expectancy (Inequalities)

Richard Bacon Excerpts

Thursday 3rd March 2011 Westminster Hall

[Margaret Hodge]

My hon. Friend makes a hugely important point, and I want to spend quite a lot of my contribution talking about the distribution of general practitioners, and the relationship between that and health inequalities.

As a Committee, we believe that addressing health inequality should be at the heart of every Government. All MPs from all political parties share the desire and commitment to work towards eradicating those inequalities. It is because it is a shared ambition that our report makes particularly depressing reading. The previous Government came into power publicly committed to reducing health inequalities, so there was a strong political commitment to achieve progress in the area. During the 13 years of that Government, there was a huge injection of money into the health service, which resulted in welcome improvements for everybody, including increases in life expectancy among the whole population. We now have life expectancy for men of 78 years and for women of 82 years. In our session on pensions yesterday, we received evidence from the King’s Fund that showed a massive improvement in life expectancy over the past decade or so, whereas in the last century there was hardly any improvement.

Given the general positive trend, it is horribly depressing to see that, while the health of the nation as a whole has improved, the gap between the richest and poorest, as measured by life expectancy, has widened. If we compare the life expectancy of men in the spearhead authorities—the most deprived authorities, in which a quarter of the population live, that were selected by the previous Government—the absolute gap and the relative gap increased between 1998 and 2007-09. In absolute terms, the increase was 8.6% and in relative terms it was 4.6%. If we look at the same statistics for women, the absolute gap increased by 9.3% for women and the relative gap by 6.5%.

What is so worrying about those statistics is that the gap between the richest and poorest women is growing at a faster rate than the same gap between the richest and poorest men. As yet, we do not have any good answers for why that is—unless the Minister can help us—except that women are smoking more today than they were a generation ago and are, therefore, more prone to diseases such as lung cancer that then kill them. I urge the Government to do some better evidence collecting so that we can understand what is happening and see whether we can take appropriate action to improve the figures.

Given our real determination to tackle health inequalities, why have we failed so far, and what should this Government do to improve performance and therefore close those unacceptable inequalities? We all understand that this is a hugely difficult area, and it is not just an issue for the health service; inequalities arise from socio-economic factors. If we consider the evidence, most of the inequalities—between 80% and 85%—come from socio-economic factors, such as income, education and housing, and probably between 15% and 20% arise from poor access to good-quality health services. It is important, therefore, that the health service does what it can. If it performed better, we would reduce that gap, but on its own it cannot tackle the problems of life expectancy that arise from whether someone is rich or poor or where they tend to live.

If we accept the importance of those wide socio-economic factors, it is vital that we have a comprehensive and coherent approach across Government. Integrating health inequalities into the wider agenda of tackling poverty inequality becomes hugely important. Without wanting to be politically partisan, I have to strike a warning note about the proposed cuts in public expenditure, which look as though they will hit the poorest hardest. If that is the case, I have not yet seen anything that provides me with the comfort that the direction of travel will reduce inequalities. In fact, quite the contrary, inequalities could be intensified. Will the Minister address that issue in her response to the debate?

I urge the Government to keep a focus on health inequalities as part of their agenda of tackling poverty and general inequality, and to judge all the actions that they take by how they will impact on health inequalities. That focus is hugely important.

[Mr Richard Bacon (South Norfolk) (Con)]

I agree with the right hon. Lady that the Government need to maintain focus. I noted that our Committee’s report says that the Department of Health itself acknowledged that it was slow to put in place key mechanisms to deliver its target and that it had used such mechanisms in other areas such as treatment of cancer, diabetes and stroke, where national clinical directors have proved quite successful. Does she think that there is scope for doing more in that regard in relation to health inequalities?

[Margaret Hodge]

Absolutely. I am grateful to the hon. Gentleman, who took through our recent inquiry into cancer. That inquiry demonstrated that, if there is that focus, outcomes will improve, although we can always do better. Having set the context in my opening remarks, I was going to make that point: access to and the responsiveness of the health service are hugely important. We need to do a lot of work to improve those things.

Tackling health inequality must be a real priority for everybody involved, which is the first lesson that we learned from our inquiry. It is not just about the politicians, for whom it has always been a priority. It must be a priority for the Department of Health, the new NHS commissioning board, GPs and all health service providers, local authorities, pharmacists and all others who have an interest in ensuring that we are healthy and live longer.

There is a criticism to be made of the previous Government. They were good at writing policy papers, but less good at following through those policies with specific actions. There were plenty of papers. We had the commitment in 1997, when the Government came in. We had the Acheson report in 1998. We had a target in the comprehensive spending review in 2000, which was pretty general but was about reducing inequalities. We had a refined target in 2002, which was more specific but perhaps a little less ambitious, and was aimed at reducing inequalities by 10% in the 20% of health authorities where there was the lowest life expectancy. We had a plan of action in 2003. That is an interesting point to pause at, because that plan of action had 82 so- called commitments. I do not think that our Committee looked at the plan in detail. I certainly have not done so. By December 2006, the then Government claimed to have met 75 of those 82 commitments, but we know from the statistics that the outcomes grew worse in terms of inequality. So there is something to be learned from the focus of that plan of action.

In the 2004 comprehensive spending review, the then Government revised and revisited the target. Again, we focused on it. We made it slightly less ambitious but more specific by focusing on 70 spearhead areas of the country. However, there is a danger with that approach, because more than half of the people who have an unequal life expectancy outcome at present do not live in those 70 spearhead areas. Inevitably, therefore, by concentrating action on those areas, we were leaving out far too many people.

Finally, in 2006—nine years after the previous Government came into office—reducing inequalities became one of the top NHS priorities. I think that it was at that point that we started to get things right. One of the lessons to learn from that is that, if we are not specific and focused, and tackling health inequality is not a high priority, we will not deliver, despite having the best intentions. In 2007, we got the primary care trusts to report on the progress that they had made on health inequalities.

Therefore, the view of the Committee is that reducing health inequality must be an explicit priority throughout the system and that it must be measured. I hope that the Minister will agree with that comment and I look forward to hearing her response to learn how she will ensure that the agenda on reducing health inequality is taken forward by this Government.

--- Later in debate ---

[Mr Richard Bacon (South Norfolk) (Con)]

It is a pleasure, Miss Clark, to join under your chairmanship this debate on my favourite subject, the Select Committee on Public Accounts, along with the right hon. Member for Barking (Margaret Hodge) and other Committee members, as well as one of my favourite Ministers, the Under-Secretary of State for Health, my hon. Friend the Member for Guildford (Anne Milton). This three-hour debate is sparsely attended. I was a little worried that we might not fill the time, but then I reflected on the old maxim by Fidel Castro that a speech less than three hours long cannot possibly do anyone any good. Although I will not take off my jacket, I am prepared to be expansive should the need arise.

To be serious, although I do not plan to take up too much time, I think that the report is valuable. It points to something much broader than the single issue of health inequality, although that is an interesting and important issue. We begin our report by pointing out that in 1997, the new Labour Government announced that they would put reducing health inequalities at the heart of tackling the root causes of ill health. That was stated as a clear policy—it is not particularly politically controversial; most people would support it—yet many years later, here we are.

When my right hon. Friend the Work and Pensions Secretary was in opposition and doing a lot of work with his think tank, the Centre for Social Justice, he drew attention to health inequalities in Scotland. They are, strictly speaking, outside the terms of our report, but many people were shocked to learn—Scottish MPs probably knew this, but I did not—that the life expectancy in parts of Glasgow is lower than in the Gaza strip. My right hon. Friend did a lot of work on that issue in opposition, and he is now in a position in the Department for Work and Pensions to help others, including my hon. Friend the Minister, do something about it.

The issues are difficult and vexing, but they are not massively politically controversial, although the report shows that the gap between asserting the intention to do something and actually delivering it is often huge. That is the experience I have had many times in many different areas during the 10 years I have served on the Committee. Often, when Ministers are expanding on any number of subjects, my hon. Friends talk as if everything will be okay, just because it is our political party that is now discussing these things. When the Government make announcements of any kind, I think that, in a few years, we will be getting a National Audit Office report about all the things they forgot to do, all the things that went wrong and the eight common causes of project failure that they failed to observe.

My attention was drawn to a comment by the new hon. Member for Walthamstow (Stella Creasy), who is a new member of the Committee. She brings a lot of extra intellectual firepower to the Committee; indeed, she has a PhD from the London School of Economics. My right hon. Friend the Member for Barking—I will call her my right hon. Friend in this case—and I are also alumni of that fine institution. I believe, however, that the hon. Lady did not pay a large management consultancy to do her fieldwork for her, in the way that this morning’s newspapers say Saif al-Islam did. That aside, she said in a recent debate:

“Governments should not just start projects or policies—the public expect them to be able to finish them too. Essentially, implementation is as important as ideology in politics.”—[Official Report, 16 December 2010; Vol. 520, c. 1134.]

The interesting thing is that we are not even talking about an area where ideology is that important. There is general agreement that changes would be a good thing, but it has still proved extraordinarily difficult to make the progress that we would all like.

The report is divided into three sections. We started by looking at the weaknesses in the approach taken by the previous Government. One of the most shocking things for me was that, in a period when life expectancy overall has improved, the gap between the national average and what we term the spearhead areas has actually widened, as the right hon. Lady said. Under the previous Government’s approach, more than half the local authority wards in the bottom fifth for life expectancy were outside the spearheads, so there was not the slightest chance they would be covered, even though they had some of the worst figures. In fairness, the Department has recognised that its targeting and leadership were not adequate and that it was slow to put in place the right priorities.

There is considerable scope for the Department to take further the model of a national clinical director, which has been applied with considerable—I will not say unqualified—success to areas such as the cancer reform strategy. As the right hon. Lady said, we took evidence on that strategy and published a report on it this week, and it showed, in addition to some success and improvements, that there were still quite shocking variations. For example, there was an eightfold variation in the preparedness of GPs—I nearly said MPs, as well—to refer patients to cancer specialists, and that variation cannot be explained by socio-economic factors. In that respect, we had a fascinating hearing earlier this week with, among others, the King’s Fund, the chair of the Royal College of General Practitioners and a general practitioner running a consortium covering 180,000 patients in Essex. The fact that they took quite different views of the Government’s proposed reforms and GP consortia led to a fruitful dialogue, and the process of creative tension and debate meant that we got quite a lot of extra information that we might not have got if all the witnesses had believed and said the same thing.

It is clear that there were weaknesses in the approach that was taken, and I would like to hear more from the Minister about what proposals the Government have to make specific improvements and whether the idea of a clinical director should be taken further. I say that especially in the context of pushing public health budgets out to local authorities, because there will potentially be more stools for things to fall between. The Department of Health will presumably drive any national clinical director programme, but the influencing will be done with people in local authorities.

The second issue that the report looked at was the role of general practitioners. The hon. Member for Blaenau Gwent (Nick Smith) is right that, according to the Department, the GP contract does not give GPs enough of an incentive to focus on the neediest groups, although part of me wonders why there should need to be an incentive. I know from my experience of talking to GPs that people who go into medicine and general practice take a very holistic approach to their patient group. They will ask some patients to come in once every three or four weeks for no other reason than to keep an eye on them. They are fearful for such patients because they come from certain socio-economic groups and probably need an extra eye kept on them. However, let us take it at face value that the Department believes that the GP contract in its present form is not adequate.

[Nick Smith]

I am struck by the hon. Gentleman’s point about GPs. Every GP I have met absolutely throws themselves into their job, and, with very few exceptions, usually does a fantastic job. However, after the evidence session, I could not help thinking that people will do what we pay them to do. If we get the incentives right and we are clear about the targets and the benefits of the activity that the Department, health board or primary care trust has emphasised, we will get better results. We need GPs absolutely to focus on the important topic before us.

[Mr Bacon]

That is right: people will do what they are paid to do. One criticism I have also heard is that the more we treat people like employees, the more they will behave like employees. In recent years, a lot of GPs have felt more bossed around, so they act like employees, rather than people who are running their own organisations.

[Ms Abbott]

Is it not also the case that in inner-city areas, such as the east end of London, large numbers of people who are reservoirs of disease are simply not on GPs’ lists? As we move to GP commissioning, it will be important that GPs commission for the population, not just for the people who happen to be on their lists.

[Mr Bacon]

The hon. Lady makes an important point. One issue is the number of GPs in deprived areas, and a chart in the report shows the variation in those numbers. At one extreme, we have about 110 or 115 GPs per 100,000 of population, although that figure is an outlier, and the rest of the figures start at about 80 GPs and go down to an average of about 59 or 60. At the other extreme, in Redcar and Cleveland, the number of GPs per 100,000 of population is only 25. In other words, there is a fivefold differential between the best and the worst. Even if we cut out the extreme outliers, the figures still go from just over 40 to about 80, which is double. If there are not enough GPs in a given area, it will be that much more difficult to identify and get on to the GP list all the people we should—those whom the hon. Lady calls reservoirs of disease. That is an important public health problem, as well as a policy problem in terms of where GPs sit.

If the Minister does not mind, I would like her to comment on single-practice GPs. Although the proportion of such GPs has dropped from 34% to 22% in the most deprived areas, there are still 371 single-handed practices. All other things being equal, a single-handed practice is almost certainly not a good idea. There may be good reasons why one exists in a particular locality, and it is certainly likely to be better to have a single-handed practice than no practice, although Dr Harold Shipman comes to mind. There is also the fact that a GP is much more likely to work well if they are with a group of people than if they are by themselves; most of us work better in groups than we do wholly by ourselves. I would be interested to hear the Minister’s comments on policy on single-handed practices and where the Government think we are heading on that. As I mentioned, I should also like to hear her comments on the proposed outcomes framework, and how she thinks the changes in the GP contract will make the kind of difference that is needed, both in getting GPs into the right areas, and in making sure that they focus enough on health inequalities.

The third part of our report applied the lessons to the wider NHS. There is of course considerable discussion and controversy about the Government’s health reforms. We are not a policy Committee, so our report does not address whether the GP consortia reforms are a good idea. People have different views on that. I have my own, and instinctively I have always been in favour of giving more authority and power to GPs, for one simple reason, which is to do with what happens whenever, in the 10 years in which I have been a Member of Parliament, I have sat down with a group of GPs. I accept that what happens may be because, although South Norfolk is not economically very prosperous, it is not massively deprived either, and it is a pleasant place to live. Some might even call it leafy, but we have plenty of socio-economic problems, and employment problems. I do not want to gild the lily, but it is not in most respects a deprived area compared with many others, so perhaps the GPs I meet are a biased sample. None the less, every time I sit down with general practitioners, from whichever practice in my constituency they come, I always walk away thinking, “My, what a sensible bunch of people. If only they were given more control and power in the running of the health service. Things would almost certainly work better.” Of course, the Government’s proposals are in that direction, so my instincts are to support what they are doing.

My experience of 10 years on the Committee, however, is that whenever the Government try to change anything of any kind, anywhere, they always underestimate the risk and over-egg the benefits. There are considerable risks to the change, including the fact that it is a change. All change, particularly when it involves big management change, raises risks. It is likely, I think, that the best of the people working in the primary care trusts, if they are good at managing health consortia, will be hired to do the job. If things works out as well as we all hope, we shall probably end up with better management, and fewer and better-paid people doing a sharper, leaner job than has happened with primary care trusts. In addition to lots of meetings with GPs over 10 years, I have had plenty of meetings with the primary care trusts in my constituency. When I was first elected, there were six PCTs just for my constituency, which was then one of eight in Norfolk, with a total population of 800,000. Each had its own finance director on a six-figure salary, and not all were particularly well qualified, which may be one reason why the PCTs began to get into serious financial trouble a few years ago, despite the fact that the NHS was receiving record funding increases.

I have probably dwelt on the issue a bit too long, and I am not trying to make a political point. I merely say that I instinctively have a degree of support for what the Government are trying to do in the context, but it still gives rise to a series of questions. I was quite surprised when I heard that public health would be moving away from the health service towards local authorities, because, on the basis of my experience of my local hospital, which is a good and fairly new acute hospital built in the past 10 years, and based on my experience of general practitioners, I would sooner that those responsibilities were left with clinicians than that they were given to the council.

When I see the proposal for health and well-being boards, I think “What if?” Let us think back to 1997, as the sun came up over the Thames and the then new Prime Minister Tony Blair said, among other things, that the Government were going to put reducing health inequalities at the heart of tackling the root causes of ill health. What if he had said after a couple of years, “I know; here’s another thing we’re going to do. We’re going to have something we will call health and well-being boards, and because we are in favour of democracy we’re going to give them to local councils”? What if we had then watched as not a lot happened for the next 10 years? I am just making this up, because it never happened, but say those bodies had been established, and had not achieved quite as much as we hoped: I can see that we might have gone into the general election saying, “As for those health and well-being boards run by the council, well you’ve all read about them in the Daily Mail and we’ll be getting rid of them on day one.” I am sure it will not work out in that way, and that my hon. Friend the Minister is well aware of the risks and has them under control.

I was interested that the Department told us that the money for the public health budgets would be ring-fenced. Paragraph 22—the final paragraph of our report—said:

“The Department told us that action for improving population-wide health and reducing health inequalities would be funded from a ring-fenced public health budget.”

One of the questions I have for my hon. Friend is, “When is a ring fence not a ring fence?” I have had meetings with my local council, which is rather eager to get hold of the £11.7 million coming its way for its public health budget. It is not its impression that it will be spending it all on public health. Some of us think that it may have other priorities in different areas, which have nothing to do with public health, but which it seems to believe have merit, and for which it can make a strong case—and, indeed, many of my constituents would make a similarly strong case. I want to understand exactly what the health and well-being boards will do, and what leverage they will have over the GP consortia, to ensure that they deliver the priorities they are supposed to—or what other methods there will be to make sure that the consortia deliver those priorities.

That all comes back to what I was saying earlier to my hon. Friend about the need for greater clarity about ensuring that the outcomes framework and the new GP contract deliver what they are supposed to. I do not care whether it is health and well-being boards who do it, or whether they exist. I care that it should happen, and it is not abundantly clear to me that there is yet a picture with all the dots joined up, so that we can be sure that if health and well-being boards are carrying out that task either they will have the correct leverage over GP consortia or there will be other mechanisms in place, through the outcomes framework or the new contract, to achieve what the Government, like the previous Government, say they want to do about health inequalities.

[Ms Abbott]

It has been my experience in my present Front-Bench role that local authorities throughout the country believe, broadly speaking, that what they call public health is public health, and that they can spend the money on that. As I said earlier, they can spend it on environmental health, social care or leisure services. I am concerned precisely with the point he made: when is ring-fencing ring-fencing? Because I do not believe that the money can be effectively ring-fenced for what we would recognise as public health expense.

[Mr Bacon]

I am interested in the hon. Lady’s comments. Of course, if we made sure that every schoolchild got a tangerine every day as part of their five a day, it would not be difficult to make a strong case for that being in the interests of public health. It would not be necessary to be a member of the tangerine growers association to make that argument.

[The Parliamentary Under-Secretary of State for Health (Anne Milton)]

I hesitate to intervene at this stage, because I will have an opportunity to speak later, but I must say, as it is such an important point, that the fact that the child gets the tangerine is not the point. The point is, does the child eat it?

[Mr Bacon]

I am pleased to say that my son would eat it, if given a chance, but he has been indoctrinated by my wife to think that fruit is the best thing going. However, to go back to what the right hon. Member for Barking said earlier, that is what happens in middle-class households, where children have lots of fruit and vegetables. My son is three and one of the things he loves the most is cucumber; he adores it. I am sure it is full of the right nutrients, although I think it is 99% water. The point is that we must make sure that those messages are getting across.

When I think about a cross-section of the population of my constituency, and ask whom I would most trust to persuade a little boy to eat tangerines—the local councillors or the general practitioners—I am not sure that I would immediately plump for the councillors, particularly given the fact, as the hon. Member for Hackney North and Stoke Newington (Ms Abbott) has said, that councillors have a lot of other pressures on them and have other priorities. I asked when a ring fence is not a ring fence, but of course there is another question about whether there should be one. One thing that we apparently feel unable to admit is that if we take off the ring fences and tell people, “We mean it when we say that you at the local authority will decide what happens,” the natural concomitant will be variation between different parts of the country. The rhetoric and the argument is that it is down to local people and if they do not like it, they can choose a different councillor.

I attended a meeting with a senior Minister in the Cabinet Office. It was just after the general election and he had been to a meeting with local councillors from across the country. He relayed a story about how a group of Conservative councillors had asked him, “Right, Francis”—that gives away who I am talking about—“we have won the election, or partially won it, at least. What do you want us to do?” He replied, “I want you to stop asking that question.” In other words, the Government seriously want to give local authorities the power to make these decisions. The obvious concomitant, however, is that there will be differences in different parts of the country. If that is the case—and in the light of the fact that, even when we have tried to have a co-ordinated strategy to get the same outcomes and reduce health inequalities, we have managed simultaneously to improve life expectancy and to widen the gap between the best and the worst—how much more likely is it to go wrong when we have this degree of local autonomy?

These things always come in waves—localism and centralisation have gone backwards and forwards. Some may remember Tony Crosland saying in 1974, “The party’s over,” and I am sure that we will come to a “party’s over” moment, although it is probably a few years away yet. I am interested in what happens on the ground to achieve change, and it sounds like my hon. Friend the Minister is as well. I shall not speak for much longer, because I am keen to hear her response.

I shall conclude with one further point to make my hon. Friend’s job a little easier, although no one pretends that this is easy. Indeed, we say in conclusion 7 of our report:

“Addressing health inequalities is a complex challenge requiring sustained and targeted action. The Department’s experience to date shows that greater focus and persistence will be needed to drive the right interventions.”

That is about strong leadership, as we go on to say in that paragraph. That is why the examples from other areas, such as Professor Sir Mike Richards’s cancer strategy, may have something to tell us about what we ought to do about reducing health inequalities. We all agree on the ends, but there still seems to be a lot of confusion about which means will work best. It is important for the whole country that we sort out that confusion and start seeing improved results.

--- Later in debate ---

[Anne Milton]

I am sure that those GPs are few and far between, but it is important to acknowledge that point. I say to the hon. Lady that the world just changed. The NHS has a key role to play in helping to reduce inequalities that affect disadvantaged people, and GPs are part of that. I know that there has been a lot of debate and discussion about the issue, and bringing decision making closer to home for GPs will be an extremely important part of levering-in better commissioning and focus on public health. Services are often commissioned because people’s health is poor. GPs will be faced with the consequences of poor public health every day, and they will commission services to deal with those consequences.

The White Paper set the proposals for the establishment of the independent national health service commissioning board and the new NHS outcomes. The proposed outcome frameworks for the NHS and public health will have the promotion and protection of equality at their heart. That aim underpinned everything when the frameworks were developed and it is no less relevant now.

As the hon. Lady said, the Health and Social Care Bill introduces specific duties on health inequalities that are enshrined in law for the first time. I share her cynicism a little. Governments often enshrine duties in law, but what matters is who holds them to account. The Secretary of State will be held to account, but Parliament has a role. Although this debate is not attended by many people, it is part of that process of holding the Government to account.

[Mr Bacon]

I was interested in that exchange and the intervention by the hon. Member for Hackney North and Stoke Newington (Ms Abbott). I draw her attention to the evidence taken by the Committee on Tuesday morning from the GP running the consortium in Essex. Together with the chair of the Royal College of General Practitioners, we were exploring the fact that there is great variation among GPs that cannot all be explained by the health variations and socio-economic conditions one would expect.

It was acknowledged that there are serious and challenging questions that need to be put to GPs. The GP from Essex is involved with teaching and improving the capacities of the consortia, and he has conversations with other GPs as he goes around his patch to look at the variations. I asked him how important it is during those conversations that he is also a GP and a clinician. He said, “It is essential. I would not be able to have the conversation otherwise.” I listened to the intervention by hon. Member for Hackney North and Stoke Newington with some interest. When that conversation between the director of public health and the GP takes place, the question will be whether the GP is listening.

[Anne Milton]

There is a question of whether the GP is listening and of whether the levers exist to make the GP listen.

This is a nebulous point to make, but I have to make it. Improving public health is about changing a mindset. We always underplay the importance of not only ministerial but parliamentary leadership on issues such as this. I am talking about a shift of focus on to public health, ensuring that the professions involved in health service delivery and the professions involved in the delivery of other services that affect people’s health receive a clear message that that is now a priority for the Government. When we talk to people who work on the ground, particularly at senior management levels, we see that that message is heard very clearly by them; it does filter down. Ministerial leadership is required, as is leadership from all of us on our individual patches.

[Anne Milton]

As many people have pointed out—the Public Accounts Committee report focused on this—access to GPs is a major issue, and not just in urban areas such as Redcar but in rural and isolated communities. I will come on to that.

Subject to parliamentary approval, because the Health and Social Care Bill is in Committee at the moment, the NHS commissioning board and GP commissioning consortia will be duty bound to have regard to the need to reduce inequalities in access to and the outcomes from health care. That does not make it happen, but the duty is in the Bill and will be important. GP commissioning consortia will have to keep on improving the quality of their services, reducing geographical variations in standards. To increase the democratic legitimacy of health services, health and well-being boards will have elected councillors to represent the views of local communities.

To be truly successful, we need to be sure that the most vulnerable groups experience the most pronounced benefits. That is an obvious thing to say, but it is important. We are therefore driving ahead with the “Inclusion Health” programme, to focus on improving access and outcomes for the most vulnerable groups. Those are often the groups of people who are not registered with GPs or who are homeless. It is important that the really hard-to-reach groups get that additional focus, because they are not necessarily swept up by the other things that we are doing. We need to keep an eye on that.

I apologise if I am incorrect, but I believe that the life expectancy of the average Traveller is 59 years. The figures for the most excluded groups are truly shocking. Therefore, I fully welcome the Public Accounts Committee report and its recommendations. They were formally responded to in the “Treasury Minutes” dated 16 February. I know that many questions remain, but those minutes give a flavour of how we propose to embed the recommendations in the reformed health care system.

We need to ensure that the GP-patient relationship is as effective as possible. If we are not talking about a family who perhaps have contact with health care services only when they have a baby, the GP is the most important point of contact. On average, families with children under the age of two will visit their GP eight times a year. That is a massive opportunity to put additional emphasis on information and action to improve the health of families. We want to renegotiate the GP contract. The idea is to ensure that disadvantaged areas get the right level of access to GPs. The way to do that, as has always been the case, is to provide incentives to make it happen.

GPs need to improve the health of vulnerable people, not cherry-pick the easiest ones at the top of the pile. They need to encourage the uptake of good-practice preventive treatments. Changes to the quality and outcomes framework prevalence adjustment reward practices in a fairer way, particularly because deprived communities often have a higher prevalence of many of the QOF conditions.

I urge my hon. Friend the Member for South Norfolk to exercise some caution when talking about single-handed GP practices. His point was well made, in that practitioners who practise independently—single-handed—do not necessarily have the best outcomes, but in saying that, we should not exclude the very good single-handed practices. I saw one such practice recently. The GP there has recently been accredited for training and was serving his community absolutely brilliantly.

We have also proposed that at least 15% of the current value of the QOF should be devoted to evidence-based public health and primary prevention indicators from 2013. That answers a point raised by the right hon. Member for Barking. The funding for that element of the QOF will be within the public health England budget.

As the Public Accounts Committee report says, the most cost-effective interventions to improve life expectancy have been developed. Now we need to ensure that they are rolled out as far and as effectively as possible. The report of the review by Professor Marmot has helped us to understand the steps that we need to take, and we shall take them. The public health White Paper adopts the review’s framework of lifelong attention, which will mean a truly cradle-to-grave approach.

In thinking about public health, we must not forget that that is not just about physical health. It is also about people’s mental health and well-being. We need only consider some of the difficult issues that surround young people when they are growing up. We can consider the incidence of sexually transmitted diseases. In the last year for which there were figures, there was a rise of 3%. There has been good progress on unwanted pregnancies and abortions. There has been some progress on unintended conceptions among under-18s, but there are still 36,000. There are still 189,000 abortions every year, of which one third are repeat abortions. We can consider the figures for drinking and young people and the fact that 320,000 young people take up smoking every year. We have a lot to do with regard to young people’s health.

We can split health services into NHS services and public health. We can split public health further, into preventive work and curative work. What do we do when people have started to smoke or drink or have had sex when they should not have done? Then we can consider how to prevent that. There is no doubt that we need to do a great deal to ensure that young people have the skills, the self-confidence and the self-esteem that mean that they are equipped to make decisions about the difficult issues that they face.

[Mr Bacon]

Before the Minister finishes speaking, will she give way?

[Anne Milton]

I have not quite finished yet, but I will happily give way. I will not keep my hon. Friend long!

--- Later in debate ---

[Mr Bacon]

I mistook what the Minister was saying for her peroration; it was the dulcet way in which she was speaking. On single-handed practices and particularly because she mentioned mental health, I want to say for the record that I do not doubt for one minute that there are some superb single-handed practices. The point that we made in our report, at paragraph 13, was this:

“A contributory factor to low levels of GP coverage has been the presence of single-handed GP practices.”

I was also making the point that people generally work better together, and it is better for someone’s mental health as a worker if they are working with people rather than alone. I speak from experience, having worked in a large agency in London with 200 employees and then having set up my own business and worked solus. What surprised me most—apart from my clients, of course—was the amount of contact that I had in the workplace, which was much lower. That was quite an unexpected aspect of it. All other things being equal, surely it must be better for GPs to work in groups than to work alone. That is in addition to the effect that it would have on overall levels of coverage.

[Anne Milton]

My hon. Friend is right to say that it is better to work together. Peer support is important, as is peer review. The identification of children at risk in A and E is important, but it is often junior paediatricians who see such children when what is actually needed is access—it can be by phone—to someone who has been doing the job a lot longer so that they can run through with them the signs and symptoms that they have seen at A and E. That sort of support is invaluable. A single- handed GP might well miss out on that. Where there are good single-handed GPs, we should encourage them to work together—not necessarily in the same practice, but perhaps in the same building. What matters to me, and my hon. Friend mentioned it earlier, is not how things happen, but doing what works.

The right hon. Member for Barking spoke about evidence, which is crucial. She rightly highlighted the issue of cancer, which was the subject of a recent Committee report, and the need for early diagnosis and early intervention. I accept what the hon. Member for Hackney North and Stoke Newington said about not everyone having access to computers or other fancy communications equipment, although most people can text these days, so there other ways of communicating. However much the Government do and whatever is done locally by GPs on early diagnosis, at the end of the day, we rely on people going to the doctor with their symptoms.

For instance, when it comes to bowel cancer, we are not very good at talking about what is in our knickers or underpants, and men are particularly bad at it. The problem with bowel cancer is that men do not go to their doctor when they have symptoms. We need to get the information out there, but improving the public’s health is largely about giving people the information, levering them into settings and giving them lots of opportunities to do so.

The right hon. Lady said that some things are much easier to do than others. For instance, it is easier to do things on which figures can be collected. However, smoking is still difficult to deal with. We and, I think, Canada perform better than almost any other country. We have made huge progress on that front, but there is a great deal more to do.

I have probably touched on most of the matters raised during our debate, but I wish to say a final word about public health. Public health goes back a lot further than people might think. The first report into the health of the working man was the Chadwick report of the 1840s. Many remember John Snow and the Broad street pump in 1854, and the outbreak of cholera that killed 500 in the first 10 days. Then we had the London sewers in 1858 and the Royal Sanitary Commission of 1871. Interventions in public health go back a long way, but it is important to remember that most of them derived from local authority action. Public health is not just about the health service.

I sit on many committees, including two Cabinet sub-committees—one on social justice and one on public health. The one on public health is particularly successful. It brings all Departments together because it recognises that public health is everybody’s business. It is a transport issue, an environment issue, a local government issue, and an education issue. It spans all the Whitehall Departments. It therefore has to span all the ministries. One of the challenges for the Department of Health is to ensure that every Department is taking whatever action it can to improve people’s health.

I know that the matter is well suited to local government. Everyone loves to hate the local council, particularly at this time of year, but they are complex organisations, dealing with a multitude of things and they know the local community well. I want to get to the day when, instead of seeing local councillors in the council chamber arguing about whether Mrs Smith at 17 Acacia avenue puts an extension on the back of her kitchen, they are saying things such as, “It’s a disgrace that the people who live in your ward live 17 years longer than those in my ward.” That would be a real success. I look to local councillors to take up the baton and to fight for public health in their areas.

We know what we need to do in the short and long terms, and we know that it can be done. Indeed, some disadvantaged areas are already narrowing some of the gaps in health outcomes. I know that our proposed reforms will put incentives in place to drive delivery at a local level, allowing local authorities and the NHS to work together.

There are health imperatives and there are financial imperatives, but there is also a moral imperative. We in Government can spend a lot of time legislating and making regulations. A lot of things are going on at the moment; we have a very difficult economic climate, and foreign affairs are now exercising us. We have to remember sometimes that there are strong and ever-present moral imperatives to take action and to improve public health.