Health and Care Services

Debate between Stephen Dorrell and John Pugh

Wednesday 3rd July 2013 Commons Chamber

[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.

Accountability and Transparency in the NHS

Debate between Stephen Dorrell and John Pugh

Thursday 14th March 2013 Commons Chamber

[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.

NHS Funding

Debate between Stephen Dorrell and John Pugh

Wednesday 12th December 2012 Commons Chamber

[Mr Dorrell]

I am listening carefully to my hon. Friend, and I have some sympathy with him, but will he acknowledge that the arguments for those options are partly about health economics but partly related to the need to deliver better quality to those who rely on community-based services? We do not want acute cases if they are avoidable.

[John Pugh]

I agree; none the less, we both agree that there is still a huge economic problem.

Even reducing the number of managers has mixed impacts, because asking doctors to manage services or buy in management service from elsewhere has cost implications. It uses up medical time, which needs to be replaced. Then there is the blighted history of IT and the uncertain role of technology and innovation, which can increase demand but also reduce cost. Even if we see public health as the answer, it is still not a complete answer by itself, because if we do not solve the huge problem of dementia, there is no saying that prolonging life and keeping people fit will necessarily reduce overall costs in the long run. If we look at things such as rewarding doctors through the quality and outcomes framework, and so on, we find some pretty expensive deployment of public money, albeit not always to massive effect. The point I am trying to make is that there is a whole medicine chest of remedies available, but no complete agreement on precisely how or where best to use them. None of them seems to be a cure-all, and many have undesired side effects.

As we choose to use those remedies, they need to be employed with skill, judgment and the benefits of experience, because we are dealing with an almost insurmountable problem. We have to approach the problem—almost like good medicine—using the right remedy, at the right time, in the right way and with skill, judgment and experience. However, that will not result simply from using market forces or creating some sort of ersatz market—that is just another tool we might choose to use. What we want—I am sure the Minister agrees—is integrated services, which would avoid expensive duplication, cost-shunting and piecemeal provision. It would be really nice if we could exploit better economies of scale in procurement, for example, or make better use of the NHS estate. It would be nice if we could discover good practice and roll it out across the piece quickly. It would be really nice if the NHS was a well oiled and efficient machine—a truly integrated system with proper clinical networks that were properly protected. It would be nice if we got what the Minister describes as integration, which is a kind of holy grail at the moment.

However, I have a problem—I am sure the Minister has a response to it—in that we have just abolished what I think would be the best agency for integration. The strategic health authority, unloved as it was—a bit obese, misunderstood, and so on—was a vehicle that could perform that role, applying the right remedies in the right place. I must own up: we decided in the Lib Dem manifesto that we wanted to get rid of the SHA. However, perhaps over the fullness of time the NHS Commissioning Board will create something like that—quietly, privately—because to some extent, I think we all agree, it is needed. Meanwhile, there are key things we need to get on with. We can certainly improve procurement without any difficulty. We can try to release ourselves from the pointless grip of the EU working time directive, which adds appreciably to salary costs. We can also work hard to move data around the system better. There is an enormous amount to do and it is not obvious who is going to do it.

NHS Reorganisation

Debate between Stephen Dorrell and John Pugh

Wednesday 17th November 2010 Commons Chamber

[Mr Dorrell]

The hon. Gentleman is a fellow member of the Select Committee and I know from our discussions that the principle of clinical engagement in commissioning is broadly supported in the Committee. It is fair to say that none of us would support the view—I suspect the Secretary of State would not either—that clinical engagement means only GP engagement. We should see the GP as the catalyst for broader clinical engagement in the commissioning process if we are to deliver our objectives.

To deliver the Nicholson challenge, we must have strong commissioning, with clinical engagement, and we have to remove unnecessary processes that do not add value. We cannot afford to waste money on them. We must have greater local accountability for the commissioning process in order to embrace public support for change on this unprecedented scale.

[Dr Pugh]

rose—

[Mr Dorrell]

I have only 40 seconds left for my speech, so if my hon. Friend will forgive me I should like to conclude.

My key message is that as we look at the lifetime of this Parliament, I do not see the White Paper as the linchpin of reform, but as a key tool in the delivery of the reforms that are neatly encapsulated in what I have described as the Nicholson challenge.