Debate on the Address

Part of the debate – in the House of Lords at 11:33 am on 8 November 2007.

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Photo of Earl Howe Earl Howe Shadow Minister, Health 11:33, 8 November 2007

My Lords, it is a pleasure to follow the excellent and very stimulating opening speech by noble Lord, Lord Darzi. I know that the House will be grateful to him for preparing the ground so ably for a debate that is inevitably going to prove fairly wide-ranging. The subject matters of today's debate are health, social affairs and education. I am not even going to attempt to cover the full extent of those policy areas. My noble friend Lady Morris will concentrate at the end on issues relating to education and children and I shall focus, in my brief set of remarks, on health and social care.

We live in strange times. Whenever I think of the noble Lord, Lord Darzi, I heave a sigh of relief that somebody sensible is looking at health policy across the piece and is doing so from the point of view of the patient to see what is best to meet patient needs. We have high hopes of what he will tell us when he reports next year, although nobody underestimates the scale of his task.

In the mean time, the Minister has inherited an NHS that is far from being the happy and cheerful scene that some of his colleagues like to present to us. First, there are the NHS finances. The year before last, 2005-06, the NHS ran up a net deficit of over £0.5 billion, so enormous efforts were devoted to reining in the finances in the year that followed. The outturn in 2006-07 was a net surplus of £0.5 billion, although within that figure almost a quarter of NHS organisations finished the year in deficit.

My noble friend Lord James will enlighten us further on this whole subject, as he is so ably equipped to do. I hope that he will agree with me on a key point, which is that the surplus recorded last year was largely illusory. It was achieved only by dint of savage cuts to training and education budgets by strategic health authorities and by raiding public health budgets. Budgets for buildings maintenance were also heavily raided. When the outturn for the year was announced, Ministers patted themselves on the back for having saved a lot of money. However, if we look at how they achieved it, not many of us think that it is a cause for congratulations.

A similar point could be made about waiting time targets. Reducing waiting times is important and needs to be measured, but we need to remember that the target relates only to a fraction of NHS activity. The mammoth effort being devoted to bringing down waiting times distorts clinical priorities, not least because it tends to suck money in from other areas of healthcare which are not subject to targets, such as chronic long-term conditions and follow-up, emergency and maternity care.

After Gordon Brown's announcement in the summer that the Government would be doing away with top-down targets from Whitehall, it is somewhat extraordinary that the biggest target of the lot—the 18-week referral to treatment target—is still something that Ministers are pursuing so doggedly.

Labour Ministers often claim that this is the first Government to recognise and to tackle health inequalities. I happen not to agree with that. But how are they doing it? One of the public service agreement targets in 2004 was to reduce health inequalities by 10 per cent by 2010, as measured by infant mortality and life expectancy at birth. Using the figures that we have so far, both measures have got worse, not better—that is to say, worse in terms of the gap that exists between the least affluent groups in society and the population as a whole. Again, the constant raiding of public health budgets cannot possibly be conducive to achieving these targets.

What about staffing? Last spring we had the debacle over modernising medical careers. It is doubtful whether any policy failure in the last 60 years has had such a devastating effect on the morale of medical staff as the failure of MTAS. The criticisms levelled at the Government by Sir John Tooke make pretty devastating reading. MTAS has been abandoned but, if anything, competition for training places looks set to be even fiercer next year than it was this year. At PCT level, the Healthcare Commission survey has found over the past four years steadily declining levels of job satisfaction.

Where are we now heading? In July, the Prime Minister gave his vision of the health service by promising,

"to put power in the hands of patients".—[Hansard, Commons, 11/7/07; col. 1450.]

I have to say, looking at the gracious Speech, that it is hard to identify anything that is designed to take us noticeably in that direction. One might have expected to see something about individual budgets to give patients direct control over their own social care. We have been promised that for about two years, but so far we have not got beyond the pilot stage. As it is, we have the promise of the Health and Social Care Bill.

There is nothing wrong with the idea of creating a single regulator for health and social care out of those that exist at the moment; indeed, I remember that when we first debated the creation of CHAI and CSCI I advocated just that. However, one thing we can be clear about: there is bound to be disruption in the regulatory process. If we want a recent lesson in how mergers cause operational disruption, we need only look at PCTs. The Healthcare Commission's annual health check for 2006 reported that out of all the healthcare bodies, reconfigured PCTs came out worst on quality of services.

Some of us fear that within the new, all-encompassing regulator, the dominant activity will be the regulation of healthcare and that the regulation of social care will emerge as the poor relation. That may happen for a number of reasons, not the least of which is that the business of regulating healthcare has a much higher public profile and will tend to suck funding away from other activities. There are three main ways in which that can be avoided: the way in which Ofcare's management reporting lines are structured; the way in which its budgets are internally allocated; and the character of the individuals who are in charge. Even though none of those things will feature in the Bill, we will want to be reassured on all of them. By itself, a change of structure does not lead to success; the culture and the people within the organisation do that.

I should be grateful if the Minister, when winding up, could clarify two points about Ofcare. The first is whether Ofcare will have the job of assessing commissioning undertaken by PCTs. The second is whether it will retain the role currently performed by the Healthcare Commission in relation to complaints made against the NHS.

Culture is also a central issue to the reform of the GMC. In many respects, it is possible to argue that the culture change within the GMC has already taken place under the able leadership of Sir Graeme Catto. The trouble is that, as he has recognised, that change has not been enough to satisfy the public. Despite the fact that lay people now make up 40 per cent of the council, public perceptions of the GMC are of a body that, in the final analysis, looks to protect its own—hence the proposals that are coming before us.

There are perhaps two main areas of contention in the proposals. The first is the disappearance of the professional majority on the council, which some regard as the death knell of professionally led regulation and standard setting. The second is the change from the criminal to the civil standard of proof in fitness-to-practise cases. Personally, I am unsympathetic to the first complaint, but I am by no means unmoved by the other. The fear is that the change will lead to defensive and unadventurous medicine.

We are assured that in very serious fitness-to-practise cases the civil standard of proof will amount to "beyond reasonable doubt" under the so-called sliding scale. We are also told that six out of the nine professional regulators already use the civil standard without apparent problem. Yet we know that, in the family courts, child protection cases are judged on the balance of probabilities precisely because unacceptable risks must not be taken with the safety of the child. We will want a lot more detail about how the sliding scale will operate in practice before we can feel relaxed about it, especially as decisions in fitness-to-practise cases will be taken not by the GMC but by a new and completely separate adjudication body.

The backdrop to all this is the question of how we should define professionalism and, in particular, how we should encourage and foster it. Fostering professionalism is achieved not only by the threat of disciplinary proceedings and corrective action; it is also done by tapping into the sense of pride that doctors have in their own performance and by enabling doctors themselves to recognise where they may be falling short. The Minister may be aware of the Maastricht experiment, under which doctors could look at their own performance on a graph. Their performance was measured against that of their peers but was confidential. It would be interesting to know whether anything similar is being contemplated in this country.

It is perhaps good to end on a more upbeat note. I mentioned culture change. One culture change too far would have been to go ahead with the Government's proposed amalgamation of the HFEA and the Human Tissue Authority. The arguments against doing so were overwhelming and I am glad that Ministers have agreed with the advice of the Joint Committee on this issue. The Second Reading of the Human Embryology and Fertilisation Bill is due shortly and I do not propose to say much about it now; other noble Lords who are more expert in the subject will in any case deal with its provisions. Two matters are, however, likely to occupy us particularly. The first is the whole issue of embryos containing both human and animal material and the ethical considerations surrounding that idea. The second is the extent to which the regulator should be given discretion in judging which entities may be created for research under licence. We may also be occupied, although I hope that we are not, with issues relating to abortion. On this side of the House, the Bill will be debated on the basis of a free vote. It would be very helpful to hear from the Minister that the same will apply to those on the government side.

We have an interesting Session ahead of us. For my part, I look forward to giving what help I can to the task that we are privileged to have: scrutinising the legislation before us and, where appropriate, suggesting improvements. I have more than just a feeling that a few such improvements may be forthcoming along the way.