Hospital Mortality Rates

Stephen Dorrell Excerpts

Tuesday 16th July 2013 Commons Chamber

[Mr Speaker]

Order. I remind the House of the long-established and generally adhered-to convention that Members who were not present at the start of a statement do not rise to question the relevant Minister. That has long been regarded as a discourtesy, and it should not happen. I have a list of Members who arrived late, but I hope that they will not render it necessary for me to draw attention to the fact. I ask those who arrived late, in all courtesy, not to rise to their feet.

We will now make progress as expeditiously as we can, led by the Chair of the Health Committee.

[Mr Stephen Dorrell (Charnwood) (Con)]

Those who want to make the case for change in an organisation—and, after the Francis review, who can doubt the need for change in parts of the national health service—must first demonstrate the need for change. Does this review not build on the distinguished record of both Bruce Keogh and Sir Brian Jarman in demonstrating the need for change in parts of our national health service?

[Mr Hunt]

My right hon. Friend speaks very wisely. As I know he agrees, identifying problems publicly is incredibly difficult, but the way to ensure that those problems are dealt with is to be totally honest and transparent about them in the knowledge that they will be sorted out as a result, and that is what is happening today.

Oral Answers to Questions

Stephen Dorrell Excerpts

Tuesday 16th July 2013 Commons Chamber

[Dr Poulter]

The right hon. Gentleman would have done well to listen to my answer before he read out a pre-prepared question. In 2012-13, the number of bed days lost because of social care delays was 50,000 fewer than the year before. However, he is absolutely right that we need to do more to ensure better integration and better joined-up care between the NHS and social care. That is what this Government are doing, and that is why we have allocated a £3.8 billion fund to do just that in the spending review.

[Mr Stephen Dorrell (Charnwood) (Con)]

Does my hon. Friend agree that there is no solution to the economic challenges facing the health and care system—still less any solution to the quality challenges that are increasingly coming to light—that does not involve proper integration of health and care? Is not the decision announced by the Chancellor a couple of weeks ago the first tangible step of a Government delivering a policy that Governments have talked about for a generation?

[Dr Poulter]

My right hon. Friend is absolutely right, as always. He is a tremendous advocate—and has been since his time in office—of integrated health and social care, and of the transformation in the delivery of care that we need to make if we are to better look after patients with long-term conditions and the frail elderly. This Government are the first Government who are committed to doing that. Compare that with the real-terms cut in funding for social care that happened under the last Government, according to the Dilnot report.

Health and Care Services

Stephen Dorrell Excerpts

Wednesday 3rd July 2013 Commons Chamber

[Mr Stephen Dorrell (Charnwood) (Con)]

It is one of the more endearing characteristics of the House of Commons that although the motion before us and those that follow it involve £517 billion of public expenditure, it falls to a Back Bencher to make the case on behalf of the absent Financial Secretary. It is obviously a minor detail that the House of Commons should be asked to approve £517 billion of public expenditure. Also, I suspect that all parties in the House are on a one-line Whip on this minor matter.

Having made that observation on the slight absurdity of parliamentary process, I will begin by saying a word about the approach to public expenditure and health policy that the Health Committee, which I have the honour to chair, has adopted since the beginning of this Parliament. We have our differences within the Committee; it would be absurd to pretend otherwise. We were elected from different party platforms and have different views about how health care can best be delivered in our society. However, from the beginning of this Parliament, we have taken the view that there is not much point in using the Select Committee as the platform for elaborating those differences, because there are many other platforms where they may be amplified. We have sought consciously to explore areas of common ground in the delivery of health and social care, and to establish where there can be cross-party agreement.

The easy way to achieve that objective would be to avoid all the difficult political questions. We have consciously not done that—we have dealt with the difficult questions. We have talked about commissioning in the context of the Health and Social Care Act 2012. We had a hearing this morning on the developments in the Care Quality Commission. We have not sought to avoid difficult territory, but when we are in it, we look for areas of common ground. That means that we are not grandstanding on health policy, but seeking to develop a coherent or, given what I will go on to say, integrated view of how health care ought to develop on a cross-party basis.

Against that background, it is significant that we have had a consistent and serious view since the beginning of this Parliament on the questions that are raised for those who work in the health and care sector by the pressures on public expenditure that exist in this Parliament and, I believe, will exist for the foreseeable future. It is not a coincidence that the first substantive report that we issued in this Parliament was on public expenditure. In that report, the Committee coined the phrase “the Nicholson challenge”, which has passed into common parlance, to refer to the challenge faced by the health and care system to deliver quality care against the background of rising demand and, roughly speaking, flat real-terms budgets.

That challenge was articulated first not by the Select Committee or the coalition Government but by Sir David Nicholson, a distinguished public servant, in his capacity as chief executive of the national health service in May 2009. It was endorsed by the previous Government. The Committee has sought to explore the success of the coalition Government in meeting that challenge and to bring to the surface some of the choices and challenges that are implicit in the phrase “the Nicholson challenge”. Incidentally, we know that the challenge lives beyond Sir David Nicholson.

Let us be clear what we are talking about. Since May 2009, the core issue has been that resources are growing extremely slowly, if at all, while demand continues to rise. One does not need a degree in mathematics to know that if demand for health and care services rises, as it has in this and every other country for the last 50 years, by roughly 4% per annum and there is no new money coming into the system, the only way in which demand can be met is by increasing the efficiency with which the resources are used by an equivalent percentage each year. In other words, the Nicholson challenge is how to deliver health and care to the required standard—I will come back to that point—4% more efficiently year on year.

I emphasise that it is not my view, nor the Committee’s view, that there are no political choices to be made about the level of resources that are committed to health and care. It falls to the Government of the day to make those choices every year when resources are voted on, as we are doing this afternoon on the estimate of £105 billion. That represents a political choice. However, members of the Committee read the newspapers, understand the laws of arithmetic and understand the broader political environment in which we live. We hear it when the Leader of the Opposition says that an incoming Labour Government would have to live with the spending plans of the current Government, at least for their first year in office. That is, to put it mildly, an exercise in expectation management by the Leader of the Opposition.

It is against that background that the Committee recommends in paragraph 16 of the report on health and social care:

“In our view it would be unwise for the NHS to rely on any significant net increase in annual funding in 2015-16 and beyond. Given trends in cost and demand pressures, the only way to sustain or improve present service levels in the NHS will be to continue the disciplines of the Nicholson Challenge after 2015, focusing on a transformation of care through genuine and sustained service integration.”

That is an example of a recommendation that was reached on a cross-party basis. We are not signing up to decisions about funding, but saying that the health and care system faces a huge challenge to deliver more integrated services if it is to meet the quality and economic standards that are likely in any political scenario.

[Andrew George (St Ives) (LD)]

I thank my right hon. Friend for the way in which he is introducing this subject. He will acknowledge that the Nicholson challenge and the need for year-on-year efficiency gains of 4% were originally proposed under the last Labour Government. There is therefore continuity from the previous Government, through the coalition and on to any subsequent Government. Does he agree that the result of the efficiency gains must not be that NHS rank and file staff are subjected to lower regional pay and conditions, as was proposed in one region of the country?

[Mr Dorrell]

I will come on to the impact on pay later. My hon. Friend is right that the challenge antedates the election of this Government and that it increasingly looks beyond this Parliament, as did last week’s public expenditure announcements. There are specific challenges implicit in the Nicholson challenge for the coalition and for the Opposition. To my colleagues in the Conservative party, who sometimes ask why we have a ring fence around the national health service, I simply say, “Understand what you are asking.” We are already strapping ourselves to the mast indefinitely into the future of meeting a rise in demand of 4% per annum without substantial growth in real resources. Looking back, we see that the national health service has delivered a 1% efficiency gain trend rate over its first 60 years, and the national average for the rest of the economy is 2%. We are expecting the health and care system to deliver a 4% efficiency gain. To anyone believing that we are likely to be able to meet demand for health and care to acceptable standards against a background of reduced resources—in other words, more than a 4% efficiency gain year on year—I say, “Do the maths.” That is the challenge to the Conservative party.

[Richard Fuller (Bedford) (Con)]

Will my right hon. Friend give way?

[Mr Dorrell]

Will my hon. Friend forgive me if I complete the challenge so as to be even-handed, as the Chair of a cross-party Committee should be?

Some Labour Members may wish to look for ways to avoid the difficult questions posed by the Nicholson challenge, but we need to remember that if we were to try to meet demand without addressing any of the efficiency questions—to take it to the other extreme—we would need £5 billion a year of new money over and above keeping up with inflation. That is more than 1p on income tax year on year, or 6p on income tax in the lifetime of a Parliament, to meet demand in the health service, unless we address the Nicholson challenge.

The conclusion that the Committee puts to the House is that the Nicholson challenge is unavoidable. Anybody who takes any serious interest in health and care has to address it. Nobody seriously believes that any Government will put up income tax by 6p in the pound in the life of one Parliament simply to fund health and care, and nobody in my party seriously thinks that we can avoid meeting demand for health and care. If we cannot avoid meeting that demand, we have to deliver a 4% efficiency gain out of the service merely to allow it to live within the current real resource available to it. That is the Nicholson challenge, and it is why the Committee—from a cross-party standpoint—has said, from the beginning of this Parliament, that it is the most important challenge facing the health and care system.

[Richard Fuller]

I wish to challenge my right hon. Friend on the 4% efficiency requirement that is, essentially, the 4% increase in demand that we expect. I am a big believer that history is a good guide to the future, and I understand the changes in demography that will push that challenge. How much of the demand comes from a quantum increase in demand and how much from a price increase for the inputs into the health budget?

[Mr Dorrell]

I do not wish to detain the House for the whole of the time available for this debate, but my hon. Friend raises an important question about how that demand is made up. The interesting thing about the drivers of demand—rising expectations, the cost and availability of modern medicine and the implications of an increasingly elderly population—which each new Front-Bench spokesman reveals as a newly discovered truth, is that they were first discovered by Rab Butler when he became Chancellor of the Exchequer in 1951. He set up a commission to ask whether the health service was an insupportable burden. The conclusion reached then, and by every successive Government since, in this and in similar processes in other countries, is that demand can be met, but it requires a serious analysis of the nature of the demand and how resources are used effectively to deliver it.

There is a danger in discussing health and care as if they were purely an economic question, especially for those of us who have been employed in the Treasury—like you, Madam Deputy Speaker, and me. There is a danger of sounding like a Treasury Minister and implying that the economic questions are the only issues in this regard. I need only offer names to the House to demonstrate that economics is not the only issue here—Winterbourne View, Mid Staffordshire and Morecambe Bay. Our system faces huge challenges, not just to do with economics but in respect of the quality of service that is delivered on a daily basis. Put simply, it is not enough just to go on delivering the service as it is now because, too often, it fails. Implicit in the Nicholson challenge is the requirement to face profound quality challenges, as they exist in the system, at the same time as squaring the financial circle I have been describing. In some quarters, it is suggested that that is a counsel of despair—that the circle is unsquareable.

The Committee disagrees, which is why the report states, at paragraph 30:

“At a time when steadily rising demand for health and care services needs to be met within very modest real terms funding increases for the NHS and even tighter resource constraints on social care, the Committee remains convinced that the breadth and quality of services will only be maintained and improved through the full integration of commissioning activity across health and social care.”

In other words, it is the Committee’s cross-party view that it is the integration—the reimagining of what health and care need to look like—that is the answer to the questions posed both by the Nicholson challenge and the quality challenges implicit in the names that I mentioned. It is important to be clear why that is the Committee’s view.

Efficiency, as implicit in the context of the Nicholson challenge, is not just about buying a bit more cleverly or holding down costs. It is about understanding what the demand is that we are trying to meet and putting in place the structures—incidentally, I do not mean the management structures—for the delivery of care that are likely to be able to meet the demands placed on them, not over the last 50 years but over the next 20. It is reimagining and driving a process of change through the health and care system that is the only realistic challenge to the financial and quality challenges that I have articulated.

[Dr Phillip Lee (Bracknell) (Con)]

Talking of efficiency, is my right hon. Friend as shocked as I am to hear that the Department of Health spent almost £74,000 on outside consultancy to prepare for just one Public Accounts Committee hearing? If that is the case, the Department might want to lead from the front on efficiency.

[Mr Dorrell]

I am sure that my hon. Friend will forgive me if, faced with an estimate of £103 billion, I do not go through every £70,000 of expenditure. However, he has made his point.

This is where I believe the Committee has held the Government to account, although not always comfortably for the Government of the day. There is no solution to the Nicholson challenge purely through adjusting the numbers—to use a non-emotive phrase. It has been reported to the Committee that in the first two years of the Nicholson challenge, 73% of the efficiencies that have so far been delivered are attributable as follows: 16% to pay freezes, which is the point made by my hon. Friend the Member for St Ives (Andrew George)—yes, holding down wages does reduce the cost of delivery and is, in the short term, a form of economic efficiency, but it is not a long-term solution to the Nicholson challenge—and, most implausibly, 45% to just changing the tariff between the commissioner and the provider. That is not an efficiency; that is an internal transfer, a bookkeeping entry, accounting, make believe. Another 12% over the two years is put down as “other”, which is an old accounting technique for concealing not very much, usually.

[John Pugh (Southport) (LD)]

Was the right hon. Gentleman able to establish exactly how much was saved through smarter and better procurement?

[Mr Dorrell]

That is not listed, and so is probably among “other” and is not very much towards £5 billion. The 4% efficiency gain translates to £5 billion of recorded savings. The two biggest items are £2.5 billion through tariff efficiency and £850 million through pay freezes. We have not yet made much progress towards the process of reimagining care which, from a Committee standpoint, we regard as so important.

I do not propose to detain the House by going through the detail of what reimagined care needs to look like, but the headlines are clear and becoming increasingly familiar. It is complete nonsense for us to imagine that community health and care can be provided efficiently to a high quality if we retain the distinction between primary health care, community health care and social care. Primary care is divorced from community health care purely as a result of a political fix by Nye Bevan and the British Medical Association in 1947. I was not born in 1947—indeed, not many Members were born in 1947. How much longer do we have to live with the structural absurdity that was not even a plan in 1947? It does not look like much of a plan now. Reimagining high-quality efficient care to enable people to live longer, healthier and fuller lives and avoid going to hospital unnecessarily is the core challenge that the Committee believes needs to be put at the door of policy makers in the Department of Health and in NHS England.

I will conclude by picking out two key recommendations from the Committee’s report, and I am pleased to be able to say that one has been picked up by the Opposition. I am pleased to endorse their policy of developing the role of the health and wellbeing boards—created by my right hon. Friend the Member for South Cambridgeshire (Mr Lansley), the former Secretary of State for Health—as the agencies best placed to develop genuine reimagination at local level of what fully integrated, joined-up health and social care should look like. It is often described as the Burnham plan. I am happy to endorse it, because the Select Committee wrote it first and we did it building on the institution created by the coalition through the Health and Social Care Act 2012. I strongly endorse the development of the health and wellbeing boards, and so, I believe, do my colleagues on the Committee.

Joining up budgets and creating single commissioning budgets through the health and wellbeing boards is only part of the answer if that single budget then allows resources to leech away through the local authority system without checks on the limits of the definition of the services that are being secured. That is why our report recommends not just joined-up budgets and the development of the health and wellbeing boards, but an extension of the ring fence, which so many of my colleagues on the Conservative Benches do not like, so that it covers not just NHS spend but social care spend too. We did that because it makes no sense to make the case for a single health and care system, and then imagine that transfer of resource out of the NHS budget into the social care budget as free to be spent anywhere else in the local authority world.

The commitment to a ring fence makes sense only in the context of a single integrated service if it covers the whole of the integrated service. That is why I strongly welcome the announcement made by my right hon. Friend the Secretary of State for Health that increased resources from the NHS budget would be made available to social care, but only—as he made clear to the Committee yesterday—subject to that resource transfer first satisfying NHS England and Ministers, who are ultimately accountable to this House, that it will be used for social care and not for other local authority services.

I have sought to identify what I regard as the key issue facing the health and care system—the Nicholson challenge—and to recognise that it is not just about economics, but about quality. The only way we can respond to those two challenges is by rethinking a set of institutions that grew up for a different world and a different time. I welcome the fact that the Committee’s recommendations and analysis, which have been developed over three years, have been endorsed both by Labour Front Benchers, who have picked up our proposal on health and wellbeing boards, and by the coalition in the announcement my right hon. Friend the Secretary of State made last week about resource transfer, subject to an effective ministerial guarantee of a ring fence. If the Select Committee has done nothing else, it has identified common ground on which those on the Front Benches seem to be gathering.

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[Grahame M. Morris (Easington) (Lab)]

It is always a pleasure to follow the right hon. Member for Charnwood (Mr Dorrell) who chairs the Health Committee with such authority and distinction. He gave a thoughtful and helpful explanation of the Committee’s report, and made some suggestions about integrating commissioning and budgets. My hon. Friend the Member for Worsley and Eccles South (Barbara Keeley) and the hon. Member for Bosworth (David Tredinnick) also highlighted several issues, and I am proud to serve with them on the Health Committee.

We need to look at the background of what is happening because in many respects, the Government have created a situation in which the NHS is in crisis. I often refer to how we measure satisfaction with the national health service, and one established measure was the public satisfaction survey. We have seen a record fall in public satisfaction with the NHS under this Government.

The hon. Member for Bosworth referred to evidence that the Secretary of State gave yesterday to the Health Committee, in which he cited the cost savings that reorganisation had brought about. However, we must also think about some of the hidden costs of that reorganisation such as clinicians’ time. How many clinicians carrying out a management function in clinical commissioning groups in other providers find that their time is not accounted for properly? What about the opportunity cost in skills and training applied for the benefit of patients if those clinicians are engaged in a management capacity? What about the loss of experience for managers at every level? Some people may have spent a number of years working in the health service and taken an interest in structures, but we seem to be going round in circles. We broke up what we described as large monolithic structures, formed separate mental health trusts and separated community services. It seems that the wheel has now turned full circle and we are realising the benefits of efficiencies of scale and integration.

With the new structure, however, we have lost some management expertise in commissioning, organising and troubleshooting—again, that point was highlighted effectively by the Health Committee. The Secretary of State and his team respond that there has been a cost saving, but in fact the vacuum had to be filled by new structures. Strategic health authorities—an unloved institution—were swept away, but local area teams were created. It is necessary to have a strategic dimension to plan health care, particularly restructurings and reorganisations.

In my view and, I suspect, for many Members across the House, this top-down reorganisation—it was not initiated by people on the ground—has impacted on front-line services and resulted in considerable expense and disruption at a time when the NHS is facing unprecedented pressures due to budgetary constraints and growing demands on the service. We have seen that manifested at the coal face, the fulcrum, in the crisis in accident and emergency departments. Unless we seriously address those issues, there is a risk to the long-term financial stability of the NHS.

Yesterday in Committee I put on the record a rather controversial point about the Government’s claim to be maintaining funding in real terms, despite NHS inflation, which is higher than inflation in the normal economy. As right hon. and hon. Members have said, there are also a number of financial manoeuvrings—I do not know whether that is an accounting term. One concern relates to how the underspend is reallocated or returned to the Treasury, and I suspect that despite assurances from Ministers, we have seen an actual reduction in funding.

Let me draw the House’s attention once more to the letter sent to the Secretary of State by Andrew Dilnot CBE, chair of the UK Statistics Authority, following representations by my right hon. Friend the Member for Leigh (Andy Burnham). Mr Dilnot wrote that

“we would conclude that expenditure on the NHS in real terms was lower in 2011-12 than it was in 2009-10.”

[Mr Dorrell]

rose—

[Grahame M. Morris]

The right hon. Gentleman has risen to the bait and I will happily give way.

[Mr Dorrell]

The hon. Gentleman might like to read the next sentence from the same letter.

[Grahame M. Morris]

I am grateful for that. We have argued for a number of months about the real position, and we have had a number of debates in the House about whether there has been a real-terms increase or a small decrease. I heard the arguments about NHS inflation and so on as recently as yesterday.

[Mr Dorrell]

The next sentence.

[Grahame M. Morris]

I will not read that out because I will come on to the issue in a moment. First I want to talk about integration, so I will press on. Statistics published in Public Spending Statistics in July 2012 show that real expenditure on the NHS fell by 0.02% in 2011-12 and 0.69% in the fiscal year before that. I understand that those are small percentages, but we are dealing with a budget of £105 billion, including the capital element, and I think the public would be concerned because those sums are not insignificant. Those percentages equate to £740 million over two years, and we should think about what that money could buy. In my area, one of the first schemes to be cancelled when the coalition came to power was a new hospital. It was not funded through a private finance initiative but through Department of Health capital resources. That hospital would have cost £464 million, but we are still waiting for it. The figures I mentioned would have built two such hospitals.

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[Andrew Gwynne]

I agree with my hon. Friend. Had she been listening to BBC Radio Manchester this morning, she would have heard me making precisely that point. The situation at Tameside is incredibly frustrating for me and my hon. Friends the Members for Stalybridge and Hyde (Jonathan Reynolds) and for Ashton-under-Lyne (David Heyes). Whenever we meet the chief executive and chair of Tameside hospital—we do so frequently—they always give us excuses as to why Tameside is different from the rest of Greater Manchester because of the industrial legacy and poor health outcomes in the borough, but one could make exactly the same arguments for Salford: there is no reason why one part of Greater Manchester should have an excellent hospital while another has one with long-term problems.

Following that slight indulgence, I want to turn to the report and focus on four key areas. First, the right hon. Member for Charnwood made some pertinent points about the Nicholson challenge. To be fair, in previous reports the Health Committee has taken the consistent view that the Nicholson challenge can be achieved only by making fundamental changes to the way in which care is delivered. It makes that argument in this report too. It states:

“Too often…the measures used to respond to the Nicholson Challenge represent short-term fixes rather than long-term service transformation.”

The Select Committee is right about that.

If we are to sustain the breadth and quality of health and care services, we need a fully integrated approach to commissioning—something that the right hon. Member for Charnwood and others have spoken about powerfully. The Opposition agree with that. I hope that the right hon. Gentleman will agree that we have put forward bold proposals for a genuinely integrated NHS and social care system that brings physical health, mental health and social care into a single service to meet all our care needs.

We know that that approach works. In Torbay, integrated health and care teams have virtually eliminated delayed discharges. Partnerships for older people have helped older people to stay living independently in their own homes and have delayed the need for hospital care—something that my hon. Friend the Member for Birmingham, Selly Oak (Steve McCabe) rightly referred to. Where physical and mental health professionals have worked closely together, they have shown that a real difference can be made.

An integrated, whole-person approach is the best way to deliver better health and care in an era when money remains tight. As the Committee’s report notes,

“the care system should treat people not conditions.”

The right hon. Member for Charnwood was right to point out that developing the role of health and wellbeing boards is the best way to plan such integrated care. He reaffirmed that he is “happy to endorse” the Burnham plan. We were happy to hear that. He is right that there is an issue with single commissioning budgets without checks on local government. As somebody who has a background in local government, I think that he is right about the need to extend the ring fence to social care spending. Unless those budgets are protected, there will be a temptation to siphon off the money that is needed to provide the integration that we all want to see.

[Mr Dorrell]

I do not want to detain the House, but will the hon. Gentleman confirm that the Opposition support the proposals set out by the Chancellor last week that will provide exactly that principle?

[Andrew Gwynne]

I will come on to the Chancellor’s proposals. We do have concerns because there is an immediate care crisis that needs to be tackled now. There are also wider issues. My hon. Friend the Member for Worsley and Eccles South rightly raised the concern of local government that it will not have the funds to implement the new requirements in the Care Bill. We need reassurances about that.

My second point is about the cost of the Government’s reorganisation, about which my hon. Friends the Members for Easington (Grahame M. Morris) and for Birmingham, Selly Oak spoke eloquently. In the update from the Government last autumn, the overall cost was up by 33% or £400 million, making a total of £1.6 billion so far. What is that money being spent on? A full £1 billion has been spent on redundancy packages for managers, 1,300 of whom have received six-figure pay-offs and 173 of whom have received pay-offs of more than £200,000, all while the number of nursing posts has been cut by more than 4,000—six-figure pay-outs for managers; P45s for nurses.

The really unfortunate thing is that the reorganisation has diverted money and attention away from the front line. The Committee’s report notes that the reorganisation has

“had an impact on the NHS budget”.

I do not want to get into that debate. I will leave it to the UK Statistics Authority, which confirmed that spending on the NHS was lower in real terms in 2011-12 than in 2009-10, albeit marginally. We have seen reductions in NHS spending. Mental health spending has been cut in real terms for two years running, cancer spending has fallen in real terms and social care budgets have been slashed.

Let me now turn to the funding crisis in social care. The Library’s analysis, which is borne out by the Local Government Association’s statistics, shows that Government funding reductions have forced local authorities to reduce their adult social care budgets by £2.7 billion over the last three years. They have had to slash services and increase charges in order to balance their books, leaving thousands of vulnerable older and disabled people facing a daily struggle to get the care and support they desperately need.

That is why what the Chancellor announced last week in the spending review is at best a sticking plaster, or if I am feeling generous, a plaster cast. Sadly, it will not solve the financial pressures on councils, break the flow of funds into the acute sector or address the fundamental problem of two systems operating to conflicting rules.

To be fair, the Government have started talking Labour’s language of integration—the right hon. Member for Charnwood would say that it is the Select Committee’s language—but as the Committee notes, the only way to achieve what we want to see is by making fundamental system changes, which brings me to my final point, which is the Department of Health underspend.

I note that the Committee has raised concerns about the operation of the Department of Health policy on underspends and budget exchange. The small print of this year’s Budget revealed that the Department of Health is expected to underspend against its 2012-13 expenditure limit by £2.2 billion. That would be the biggest underspend of any Department in this financial year. Page 70 of the Budget document appears to show that none of this has been carried forward to be used in subsequent financial years as part of the Budget exchange programme. Perhaps the Minister could explain why—at a time when the NHS is facing its biggest financial challenge, when 4,000 nursing posts have been lost and when there is a crisis in A and E—they have decided to hand the full £2.2 billion back to the Treasury. Can the Minister also confirm that this means the underspend for 2012-13 would be 2% higher than the 1.5% figure that his Department says is consistent with “prudent financial management”?

We think that people will struggle to understand why this money has not been spent on the NHS. That is why we proposed that the Treasury exceptionally allows a £1.2 billion “end-year flexibility” carry-forward of around half of this year’s under-spend. We would ring-fence this money for social care budgets this year and next, to tackle the immediate crisis, with £600 million allocated for 2013-14 and a further £600 million allocated for 2014-15. With that extra investment, we could relieve the pressure on A and E and help to tackle the scandal of care services being withdrawn from older people who need them, enabling more people to stay healthy and independent in their own homes, and help families being squeezed by rising charges for care.

I thank the right hon. Member for Charnwood and members of the Committee—and other hon. Members on both sides of the House—for the sterling and thorough work that they have done and the powerful arguments they have made, especially on integration. They are right to highlight those issues, because it is the only way in which the NHS and care services will be able to make the necessary step changes to meet the challenges of an ageing society within the financial constraints we face. It is just as important that we get it right in terms of outcomes for patients, because the care services they receive will be greatly strengthened and improved through integration.

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[Dr Poulter]

The hon. Gentleman is absolutely right to highlight the fact that health tourism presents challenges. We need to look at them, which is why we have launched a consultation on exactly how to do so. We should recognise that we hugely value the fact—it is very beneficial to the British economy—that students come here from overseas to train and, sometimes, to work. Part of ensuring that they do so in a responsible manner and do not short-change British taxpayers and British patients means making provision for their health care needs, if necessary, and ensuring that the NHS does not pick up the tab. That is something we have opened a consultation on. It will report back later this year, and I am happy to discuss the matter further with the hon. Gentleman away from this debate.

In opening the debate, my right hon. Friend the Member for Charnwood was absolutely right to ask how we would deliver greater productivity in the NHS and to say that pay plays a part. Improving procurement, driving greater productivity and, crucially, service reconfiguration all play their parts too. It is worth highlighting the fact that the NHS needs to become more efficient at how it manages its estates, with £3.1 billion or so spent on NHS estates annually. There is much that can be done to improve the energy efficiency of those estates, which is why the Government launched a £50 million fund to support that work. A lot also needs to be done to reduce the £2.4 billion temporary staffing bill. That is something we will be talking about when we launch a paper later in the summer. There also needs to be greater focus on good leadership at board level—something we have touched on before—and engaging clinical leaders in helping to drive productivity and improvements in patient care.

It is also worth outlining the role of tariffs, which were touched on in the Committee’s report and in today’s debate, in driving more joined-up care. It is true that tariff change in itself is not good enough to drive improvements in patient care. Tariff change must drive service change and transformation at the same time, driving the more integrated care model that we all believe in. When my right hon. Friend the Member for South Cambridgeshire (Mr Lansley) was Secretary of State, he initiated a review of the tariff system and looked specifically at best practice tariffs. We are now seeing the emergence of tariff change in a way that not only reduces costs, but drives service transformation. In the case of fragile hip fractures, day case procedures—such as cholecystectomies and similar procedures—and major trauma, we are seeing service change and transformation being driven by improved tariffs, which often cut across primary and secondary care.

If we are to deliver an NHS that is fit for the future, both financially and in human terms, that will be down to major service transformation and moving towards a system that provides integrated health and care. That is why last week my right hon. Friend the Chancellor outlined in his statement a £3.8 billion fund that will be shared between the NHS and local authorities to deliver integrated services more efficiently for older people and disabled people, ensuring that health and social care work together to improve outcomes for local people. Importantly, the Health Committee’s calls for health and wellbeing boards to play a vital role in overseeing the fund is something that we envisage becoming a reality.

In conclusion, we know that there are big challenges to the NHS in driving up productivity, and we know that we have already met some of them by cutting out, through our reforms, £1.5 billion of bureaucracy in the NHS—money much better spent on patient care. Crucially, in the years ahead, we will focus on the service transformation that is required to deliver a more integrated health service, continuing to develop those best practice tariffs that drive integration and bring together health and social care. It is not just about finances, because it is also about good care, which is why it is important to deliver the integrated system that patients deserve.

[Mr Dorrell]

rose—

[Mr Deputy Speaker (Mr Lindsay Hoyle)]

Did you want to come back, Mr Dorrell? We are up against time with the next debate.

--- Later in debate ---

[Mr Dorrell]

I am not pressing; I was led to believe that it is the convention to respond. I believe I have two minutes.

[Mr Deputy Speaker]

One minute, I am sure you have.

[Mr Dorrell]

I will seek to compress the one point that I wanted to make into one minute.

I stressed the importance of the role we have sought to play in the Select Committee in developing a cross-party view of the challenges facing the health and care system. That is not the same as saying that they are not political. A cross-party view has been demonstrated by people with different constituency interests and different ideas about how, in precise detail, that shared view about the future of health and care needs to be delivered. The challenge for both the Opposition and Government Front-Bench teams is to do what their predecessors—in my time as a Minister and stretching back before me—did not do, which is to turn the rhetoric about transformational change in health and care into a reality.

What we have sought to do in the Select Committee is to sketch out the ground and indeed some of the methods by which we believe that can be done. We welcome the fact that the Labour party has picked up our views on health and wellbeing boards, and we welcome the fact that the Chancellor of the Exchequer has picked up our views about a ring fence for social care spending. There is hope for the future that a Select Committee can sketch out common cross-party ground in an area of public policy that is necessarily as political—with a small “p”—as health and social care.

Question deferred (Standing Order No. 54(4)).

department for transport

Care Quality Commission (Morecambe Bay Hospitals)

Stephen Dorrell Excerpts

Wednesday 19th June 2013 Commons Chamber

[Mr Hunt]

My hon. Friend speaks extremely wisely, and I know that the whole House will want to say how sorry we are to hear about the personal problems he had with that trust. All the international safety studies say that if we are to transform safety culture, it has to come from better leadership. It has to come from leadership that really cares; that frees up people on the front line to raise safety concerns in a way that they do not feel will be career-threatening; that encourages them to rethink procedures to minimise the risk of harm to patients; and that encourages the open and transparent approach that has enabled hospitals such as Salford Royal to become one of the safest in the country, because of the inspirational leadership of David Dalton. That change in leadership is fundamental, but having a chief inspector who goes without fear and favour and says where we have that leadership and, more importantly, where we do not have it, will be vital to ensuring that we start to get the changes that my hon. Friend is concerned about.

[Mr Stephen Dorrell (Charnwood) (Con)]

Does my right hon. Friend agree that in the long litany in this report of events that were inexplicable and completely unacceptable, one of the most inexplicable and unacceptable things it lays bare is that at the same time as concern was being expressed to the CQC about the quality of maternity services delivered in the trust, to which the CQC did not respond, the trust itself commissioned a report into the future of maternity services and did not see fit to report the existence of the Fielding review to the regulator to which it was responsible? Will my right hon. Friend make it crystal clear that that is completely inconsistent with any concept of duty of candour for health care deliverers?

[Mr Hunt]

I could not agree more with my right hon. Friend. What happened beggars belief, and I very much agreed with his comments on that on the radio this morning. The point about duty of candour is that there will be a criminal liability for boards that do not tell patients or their families where there has been harm and that do not tell the regulator; boards will have a responsibility to be honest, open and transparent about their record. That has to be the starting point if we are going to turn this around.

Children’s Heart Surgery

Stephen Dorrell Excerpts

Wednesday 12th June 2013 Commons Chamber

[Mr Hunt]

I thank the right hon. Gentleman for the tone of his comments and the bipartisan way in which he has approached these issues. I particularly welcome his last point. We have many debates in this House, but this is one issue where we are completely at one. If there is a difficult decision to be made that will save children’s lives, we must have the courage to take it. I am grateful for the right hon. Gentleman’s support on that.

I think that the right hon. Gentleman will also agree with me that while this issue transcends party politics, it is one from which all of us—on both sides of the House, throughout the NHS and indeed in local authorities—have things to learn. I think that the biggest issue for us all to consider is the sheer amount of time that it has taken. The original concerns about what happened in Bristol were raised in 1989. I am pleased to say that they have been dealt with, but there are broader, system-wide lessons to be learnt. It took until 2001 for Sir Ian Kennedy’s report to be completed, it took until 2008 for the Safe and Sustainable review to begin, and now, in 2013, we are having to suspend the process yet again. What has happened is not the right outcome for children, and we must all learn the lessons from that.

The right hon. Gentleman mentioned site selection. I consider that to be one of the most crucial areas in which the process was flawed. Whether we should involve adult heart services is a difficult question, but one of the key recommendations in the IRP’s report is that they should be taken into account. I think that we should pay attention to that recommendation, because the panel thought about it very carefully. The reason for its view was that the same surgeons often operate on children and on adults. Adults also have congenital heart conditions that require operations. The panel also says that if the best outcomes are to be achieved for children, services must be concentrated in teams that have four full-time surgeons, provide specialist training, and conduct research. The knock-on impact of what is happening in adult heart services is relevant.

I agree with the thrust of what the right hon. Gentleman said about mortality data, but I know that he will also understand the difficulty of publishing such data on a very small number of cases when they may not be statistically significant. That was one of the great debates that we had over the temporary suspension of services at Leeds. We must be careful not to publish data that could lead the public to make the wrong conclusions. In principle, however, transparency is the most important thing for us to bring about.

I entirely agree with the right hon. Gentleman about the timetable. I think that we must get on with this process: I do not want to delay it any more than is necessary. I have talked extensively to NHS England about how it should be approached. NHS England—along with all the stakeholders involved—needs time in which to digest the contents of the IRP report, which was published only today. I consider that the minimum period that I need to allow it to come up with the timetable is until the end of next month. I appreciate that that is six weeks, but I think that it is a sensible period. I certainly want to be able to publish an indicative timetable by then, so that people can understand how the process will continue and how we will learn the lessons.

I also agree with the right hon. Gentleman that nothing in my statement should undermine the public’s confidence in the brilliant work being done by heart surgeons all over the country for adults and children. Our heart surgery survival rates have improved so much that they are now some of the best in Europe, and we can be very proud of the work that those surgeons do, day in, day out. However, that does not mean that we cannot strive to be even better.

[Mr Stephen Dorrell (Charnwood) (Con)]

I welcome the statement, although, in a sense, I welcome it with a heavy heart. Does my right hon. Friend agree that the Safe and Sustainable process could not go ahead because it had fundamentally lost the confidence of patients and clinicians, and therefore did not form a proper basis for necessary change?

Given that it is now more than 12 years since the publication of Sir Ian Kennedy’s report, does my right hon. Friend agree that this is not a success for the NHS? Does he agree that it is a real challenge for NHS England to put a proper time frame around necessary change for these services, and then to use that as a basis for changes that we know to be needed in other specialist services in the national health service?

Oral Answers to Questions

Stephen Dorrell Excerpts

Tuesday 11th June 2013 Commons Chamber

[Mr Stephen Dorrell (Charnwood) (Con)]

Does my right hon. Friend agree that the introduction of health and wellbeing boards represents a very welcome introduction of democratic accountability into the management of the health and care system? Does he further agree that the acid test of health and wellbeing boards will be their ability to increase the pace of integration between health and care so that the service we deliver is more closely matched to the needs of patients?

[Mr Hunt]

As is so often the case, my right hon. Friend speaks extremely wisely on this issue. Integrated services will be the big thing that transforms the service we offer vulnerable older people, which the right hon. Member for Leigh (Andy Burnham) mentioned earlier. Health and wellbeing boards will have an extremely important role to play in bringing together local authorities and clinical commissioning groups so that we have joint commissioning of services for those very vulnerable people.

Accident and Emergency Waiting Times

Stephen Dorrell Excerpts

Wednesday 5th June 2013 Commons Chamber

[Andy Burnham]

Oh dear, Mr Deputy Speaker. It is hard for this Government, who have decimated social care, to lecture us about it. Between 2005 and 2010, A and E waits fell. That was after the GP contract was signed. Let us have some facts. We did much to support social care and to deliver an NHS with the lowest ever waiting lists and the highest ever patient satisfaction.

The second point in our A and E rescue plan concerns safe staffing levels—another aspect that we have raised repeatedly with the Secretary of State.

[Mr Stephen Dorrell (Charnwood) (Con)]

Will the right hon. Gentleman give way?

[Andy Burnham]

I will give way to the right hon. Gentleman in a moment.

All over the country, NHS staff are saying that there are not enough people on the ward to deal safely with the pressure that they are under. The College of Emergency Medicine has warned of a “workforce crisis” in A and E and of

“a lack of sufficient numbers of middle grade doctors and Consultants in Emergency Medicine to deliver consistent quality care.”

More than 4,000 nursing posts have been lost since May 2010 and the Care Quality Commission says that one in 10 hospitals in England is understaffed. It emerged last week that the problem is set to get worse. A survey of NHS HR directors by the Health Service Journal found that 27% of trusts were planning to cut nursing jobs in the coming year, that 20% were planning to cut doctors and that one in three was not confident that they had enough staff to meet demand.

As I have said before, all parties in this House, including my own, need to learn the lessons of the failures in care at Mid Staffs and of the Francis report. The primary cause of those failures was dangerous cuts to front-line staffing. There is a clear risk that the NHS is repeating that mistake. I therefore call on the Secretary of State to intervene in the further round of job cuts and to ensure that all hospitals in England have safe staffing levels.

[Mr Dorrell]

May I bring the right hon. Gentleman back to the interface between social care and health care? He knows that I have a lot of sympathy for the points that he made about the importance of making that interface work more smoothly than it has done for a long time. Is the House to interpret his remark that an additional £1.2 billion ought to be made available for social care as a spending commitment that has the consent of the shadow Chancellor, on the day when the Labour party has said that it will not make good the child benefit changes that it opposed earlier in the Parliament?

[Andy Burnham]

It is important for me to answer the Chairman of the Health Committee. Those of us who are in the club of former Secretaries of State understand that the health and social care systems are interconnected and must be seen as one system, because the failure of social care lands on the doorstep of the NHS.

To answer the right hon. Gentleman’s point directly, the money that I was talking about would come from the underspend. It is part of the allocated budget that his Government gave to the Department of Health for 2012-13. The Department did not spend the whole budget so there was a £2.2 billion underspend. As he knows, the practice has been that Departments can take forward that resource to meet new pressures in later years. I am asking the Secretary of State please to ask for access to that money to relieve the pressure on social care. Simply handing it back to the Treasury when there is an A and E crisis and social care is collapsing is not good enough.

The third point I want to address is out-of-hours advice and the introduction of the 111 service. Last week’s summit heard worrying evidence that the problems of 111 are not just teething problems, as the Secretary of State has claimed. We were told that the problems were more structural and were a result of how 111 has been set up—a feature of the cost-driven contracts that have replaced the successful and trusted NHS Direct. Contracts have gone to the lowest bidder, and they are saving money by having inexperienced call handlers working to a computer algorithm that too often results in the advice “Go to A and E”. There has also been a huge reduction in nurse-led call back, which was the norm with NHS Direct.

--- Later in debate ---

[Mr Stephen Dorrell (Charnwood) (Con)]

I welcome the fact that we are debating increased evidence of service pressures in the national health service. Having attended health debates in the House of Commons for quite a few years, I can say that there is a depressingly familiar tone to this debate. May I tell the right hon. Member for Leigh (Andy Burnham) that if we want to develop party points in the House and convince the electorate that there is something in it, it is not a bad idea to begin by establishing where the real differences exist between the Government and the Opposition? If we look at the evidence for why we have experienced increased service difficulty in the health service, we see that it is not the differences between the Government and the Opposition that are striking but the fact that there is a shared analysis. However, there is an apparent unwillingness to apply that analysis and work it through in the necessary large-scale service change that we require.

As for the roots of increased service pressures in the health service, I agree with quite of lot of what my right hon. Friend the Secretary of State said about the GP contract, but that is not why those pressures exist. Their true roots go back to the time in which the right hon. Member for Leigh was Secretary of State. In 2009, David Nicholson said that demand would go on rising in the health service, and that given the state of public finances we had to find ways of meeting that demand without continuing to make calls on the taxpayer on the scale that we had grown used to over the first 60 years in the history of the health service.

[Steve Baker (Wycombe) (Con)]

In Wycombe, ever since our A and E was closed under the previous Government, people have wanted nothing more than to get it back. It is clear that medicine has changed and that they will not do so, but does my right hon. Friend agree that there has been a long-standing failure to explain those pressures to the public?

[Mr Dorrell]

I absolutely agree with my hon. Friend. We cannot blame people in the country for not understanding the need for change in the health service if politicians never explain why that need has arisen. I quite often quote Enoch Powell—not someone who wins a consensus across the House—who as Health Minister went to the equivalent of the NHS Confederation conference, which is now under way in Liverpool, to explain the need for the change in the service model in mental health. He said in his speech that

“Hospitals are not like pyramids, built to impress some remote posterity”.

That is the case that we need to begin to explain.

[Chris Bryant]

rose—

[Mr Dorrell]

I shall give way once more.

[Chris Bryant]

I am grateful for the right hon. Gentleman’s generosity. One of the ironies is that Enoch Powell recruited a lot of doctors overseas. He would have had absolutely nothing to do with the argument advanced yesterday by one of the right hon. Gentleman’s colleagues that all the problems in A and E are to do with the arrival of migrants. If anything, we need to change immigration policy in this country, so that more doctors can come here.

[Mr Dorrell]

I have four minutes, or with two interventions, six minutes, so if the hon. Gentleman will forgive me, I shall not go off into a discussion about immigration policy.

I want to focus on the changing needs that the health service has to meet. I sometimes wonder whether people talking about rising demand on the health service and rising demand for emergency care have ever sat in a GP’s surgery. Have they noticed around them in a GP’s surgery the kind of people who present in a surgery and the conditions that bring them there—dementia, diabetes and drug and alcohol abuse? How can we expect a service that was designed to meet the needs of patients, inasmuch as it was designed at all, in the 1950s, 1960s and 1970s to meet the needs of today’s increasingly elderly and dependent patients, without rethinking the way care is delivered?

This is—I come back to my core point—a shared analysis. It is not a subject of party political debate. It is a shared analysis between the two Front Benches, and what is even more surprising is that not only is the analysis shared, but the conclusions about the right policy response are shared.

[Andy Burnham]

Will the right hon. Gentleman give way?

[Mr Dorrell]

Forgive me. I have a minute and a half and I want to develop what I think is an important point.

When I make the case for greater urgency about integration between the different parts of the health and care system, I am often told that I am supporting Andy Burnham’s plan. I am quite happy to support Andy Burnham’s plan. Actually, I gently claim credit for the fact that the Health Committee on a cross-party basis has been advancing this analysis from the beginning of this Parliament, and with due deference to the right hon. Gentleman and to my colleagues on the Select Committee I will also point out that part of the answer that the right hon. Gentleman is—rightly, I think—advancing builds on health and wellbeing boards, which are the creation not of me or of him, but of my right hon. Friend the Member for South Cambridgeshire (Mr Lansley), the former Secretary of State for Health and now the Leader of the House of Commons.

The right hon. Member for Holborn and St Pancras (Frank Dobson) talked about a duty of candour. Could we not have a duty of candour about agreement in the House of Commons—agreement that what needs to happen is not to find artificial divisions, but to build on the need for urgent change to meet the needs of today’s patients?

A and E Departments

Stephen Dorrell Excerpts

Tuesday 21st May 2013 Commons Chamber

[Mr Hunt]

And I would always seek to do so, Mr Speaker.

Finally, the right hon. Gentleman constantly seeks to run down the performance of the NHS. Where is the recognition of the outstanding performance of the NHS under this Government: the fact that under this Government 400,000 more operations are happening every year than under Labour; the fact that the number of people waiting for more than a year for an operation has gone down from 18,000 under Labour to fewer than 1,000 under this Government; the fact that MSRA rates have been halved; and the fact that mixed-sex wards have nearly been eliminated? We will stick up for the great achievements of our NHS and we will not allow people to run it down. However, we will also tackle problems honestly and ensure that we address crises, many of which were caused by the previous Government.

[Mr Stephen Dorrell (Charnwood) (Con)]

Does my right hon. Friend agree that patients seeking urgent care will go to that part of the health service where the lights are on, and that the failure of the Opposition, over 13 years, to create genuinely integrated emergency care is the fruit we are now harvesting?

[Mr Hunt]

As ever, my right hon. Friend speaks with great wisdom. When it comes to the frail elderly, the key is to have a system that heads off problems before they arrive so that people do not find that they end up having to be rushed into A and E in the middle of the night. That can often be the very worst place for someone with advanced dementia or any condition that makes them extremely fragile and vulnerable. We need to integrate systems properly, and that did not happen under the previous Government. One of the key work streams of the vulnerable older people’s plan will be to look at barriers to integration, particularly the barriers to joint commissioning of social care and health. We intend to make good progress on that front.

Oral Answers to Questions

Stephen Dorrell Excerpts

Tuesday 16th April 2013 Commons Chamber

[Mr Hunt]

I agree with the hon. Gentleman. Some of the devolved Administrations, particularly Scotland, actually do better than England in regard to dementia diagnosis, and one thing that we must learn from them is the value of a properly integrated care plan. I am working closely with the Minister of State to ensure that we deliver that in England.

[Mr Stephen Dorrell (Charnwood) (Con)]

My right hon. Friend said in his answer to my hon. Friend the Member for Fylde (Mark Menzies) that certain aspects of the treatment of dementia patients had to change. Does he agree that that should include the services that are delivered to them becoming more integrated, not only between hospitals and community health care services but between social care services and social housing support, in order to provide a proper joined-up package of care for people who receive such diagnoses?

Accountability and Transparency in the NHS

Stephen Dorrell Excerpts

Thursday 14th March 2013 Commons Chamber

[Mr Stephen Dorrell (Charnwood) (Con)]

I want to follow the hon. Member for West Lancashire (Rosie Cooper) on to very similar territory. She and I both sit on the Health Select Committee, which I chair. I want to start where my right hon. Friend the Secretary of State and the right hon. Member for Leigh (Andy Burnham) started, with what happened in Mid Staffordshire. It was shameful, and we will be judged today by whether we show a serious willingness to learn and apply the lessons of the Francis inquiry.

Francis made 290 recommendations, but they amount to just one core recommendation, which is that there needs to be a fundamental culture change through the whole of the national health service. With respect to the shadow Secretary of State, that is the sense in which challenges are posed for the health service way beyond Staffordshire. We have to learn the lessons of Staffordshire and apply them beyond it, as well as demonstrating that we understand what we mean—in the modern jargon, we “get it”—when we talk about the need for a culture change.

My hon. Friend the Member for Bristol North West (Charlotte Leslie) encapsulated that when she used the words “accountability” and “transparency”. I will not follow her down the route that she took in her speech. I want to focus exclusively on what we mean by those two words. They seem to trip too easily off the tongue, without anyone understanding what they mean, and that must change if we are to sustain a culture change in the health service.

My first proposition is that accountability without transparency is entirely meaningless. The ability to see what is going on and how decisions are being made in the health service, and to see the effects of those decisions, is fundamental to the delivery of the objective of culture change. With respect to the right hon. Member for Leigh—and, indeed, to some of the points that my right hon. Friend the Secretary of State made—we have to acknowledge that a lack of transparency lies deep in the culture of the health service, and that it goes back to way before the previous Government were in office. It was present in my time as Secretary of State and well before that, too. I was regularly accused of supporting a gagging culture in the health service, although nothing could have been further from my intention. However, that charge was made against me, against the right hon. Members for Leigh and for Kingston upon Hull West and Hessle (Alan Johnson) and, in truth, against all our predecessors right back to 1948.

The instinct to protect, rather than the instinct to reveal, is deeply embedded in the health service. When something is said to be going wrong, there is an instinct for the wagons to gather round. That is why Francis’s recommendation for a duty of candour is key to the delivery of the objective of greater accountability and transparency.

[Barbara Keeley]

Was the right hon. Gentleman as disturbed as I was to hear that the £500,000 gag at the United Lincolnshire Hospitals NHS Trust was put in place without any sign-off whatever, on the basis that it had involved judicial mediation? The Secretary of State refused to answer my question about this. Does the right hon. Gentleman agree that the Secretary of State really has to stop that, because it involved a very large amount of money, which was used very ill-advisedly?

[Mr Dorrell]

The position I take is the one set out in the Francis report, which was explicitly endorsed by Sir David Nicholson in the Select Committee inquiry to which the hon. Lady has referred. I believe that it would also be endorsed by my right hon. Friend the Secretary of State, but he must speak for himself. That position is that it is hard to imagine circumstances in which the use of public money in the context of a compromise agreement should be governed by a confidentiality clause. In an age when a bill from Pizza Express has to be published on the internet, decision makers should be held publicly accountable for the use of large sums of money in the context of a compromise agreement.

[Mr Jenkin]

I accept my right hon. Friend’s challenge about openness and transparency in the way the health service reacts outwardly, but that is a means to an end. There is also a lack of honesty and openness between people working in the health service, and the mistrust between levels of management and institutions inhibits the proper flow of information and the ability of people to trust each other in the context of saying what is wrong and putting it right. People in the health service dare not tell their senior management what is wrong.

[Mr Dorrell]

I have a lot of sympathy with what my hon. Friend says. The successful delivery of a culture change that supports real transparency would build on the fact that it is not only a right but an obligation for a registered doctor or nurse who sees care being provided that falls below proper standards to raise their concerns and, if no action is taken, for those concerns to be raised with the regulator. Change will be required right through the health service if that professional obligation is to be made real.

[John Pugh (Southport) (LD)]

My right hon. Friend has mentioned the instinct to protect and to circle the wagons. Would he accept, however, that that is not exclusive to the NHS, and that it also exists in the police service, for example? It also existed in Parliament during the expenses scandal. It is an institutional feature of many kinds of organisation.

--- Later in debate ---

[Mr Dorrell]

I agree with my hon. Friend, but I hope he will forgive me if I do not follow him down the road to the police service in the three and a half minutes I have left.

My key objective is to enable Members to recognise that this is a deep-seated cultural issue, that we need to create a more open culture, and that a duty of candour is fundamental to that. I say to the right hon. Member for Leigh that we need to ask ourselves occasionally: accountable to whom? Surely in the first instance, the health service must be accountable to the patient. How can it ever be right for a failing in care provision that has been acknowledged and discussed not to be described to the patient? That duty of candour to the patient is fundamental to the culture change that I am describing. However, we have to remember that, within the tax-funded health care system, there is a duty not only to the patient but to the taxpayer. Although I do not want to go too far down this road, the challenge for the right hon. Member for Leigh when he speaks about competition and decisions about the use of public money is that commissioners and providers must be accountable for value as well as clinicians being accountable for quality.

In my remaining time, I want to pose this challenge for those elected to this House. The challenge of culture change has to apply right through the health service, but people looking into this debate from outside will, I suspect, conclude that thus far that challenge has not been fully responded to. There is a deep-seated culture here that pretends that the problems all started under this or that lot, or that every success is the result of achievements made by one particular side, but the truth is that this deep-seated requirement for culture change has been addressed by successive Governments over a protracted period.

We should not forget that waiting time targets were invented before I was Secretary of State for Health. Quality of care requires access to care as well as to high-quality clinical outcomes. We should not forget that deep in the pathology of what happened in Staffordshire, the health economy there was out of control. It was running sustained deficits and management was required to bring that health economy under control. There is no choice between quality on the one hand and management on the other. We need to develop a culture within the health service that allows managers to address questions of both quality and value, because unless we address both, we will deliver neither. That is the core challenge facing the health service over the period ahead.