I beg to move,
That this House
calls for an inquiry into the circumstances surrounding the decision in July 2002 to upgrade the star rating of the South Durham Health Care Trust from two stars to three following the involvement of the private office of the then Secretary of State for Health and with the knowledge of 10 Downing Street;
further calls for greater transparency in the calculation and publication of performance indicators throughout the NHS;
and is concerned that excessive reliance on such indicators inhibits the independence of professionals and managers and leads to distortions in the allocation of resources.
I draw the attention of the House to my entry in the Register of Members' Interests.
I am delighted that on its third day back at work the House has the chance to debate the circumstances surrounding the award in July 2002 of three stars to the South Durham Health Care NHS trust. We are indebted to the Health Service Journal for exposing those circumstances in a report published on
Let us examine the sequence of events. On
The list of star ratings was attached to the paper, showing an increase in the number of hospitals receiving three stars compared with the 2001 awards. Mr. Wilmore explained that despite the overall increase in performance
"there are still a few high-profile trusts which we might have expected to be three stars which are not."
His next comment, according to the report in the Health Service Journal, is significant and I shall quote it in full:
"Unfortunately, even if time allowed it, further revisions to the methodology to promote these trusts would inevitably lead to other individual results we have not expected, as well as making the scoring system more complicated."
In the view of Mr. Wilmore, tinkering with the basis for calculating star ratings at such a late stage would be undesirable.
The then Secretary of State disagreed. Three days later, on
"urgently revisited with the Commission for Health Improvement."
The same e-mail from the Secretary of State's office went on:
The e-mail no doubt anticipated the questions that the Prime Minister was likely to put and it had the desired effect. The very next day, on
"Alterations to the methodology have been made resulting in the changes to individual trusts that were requested."
There can be no doubt about what was going on. That senior official received a request from the Secretary of State to make changes to the rating of the NHS trust that serves the Prime Minister's constituency. As it happened, it also served part of the Secretary of State's constituency. Imagine the relief in his office that day as his staff scanned the latest document to find that no fewer than seven more NHS trusts had now received the coveted three stars, and those seven included the all-important South Durham health care trust.
The Secretary of State had prevailed. He had found a way—no matter at what cost in terms of lost integrity—to manipulate the ratings. There is no indication that the changes had the approval of the Commission for Health Improvement or even that it was consulted. Mr. Wilmore's latest note contained a warning, however. It said that changing the results in the way described
"makes the scoring methodology more difficult to explain and less transparent."
There is nothing new in the hon. Gentleman's allegation. It has been made a number of times and repudiated to the satisfaction of pretty much everyone except the Conservatives. As he is concerned about the integrity of the process and the abuse of ministerial position, I draw his attention to a real case of ministerial abuse, as outlined by his Front-Bench colleague, Mr. Burns, in the Standing Committee on the Health and Social Care Bill on
Order. Interventions are usually short. The hon. Gentleman is making a speech.
That was a pretty disgraceful performance by Mr. Bailey. I hope that other interventions will address the subject matter of the debate.
Given that the formula for calculating star ratings in 2002 had just five elements and that for one of those five—clinical focus—South Durham's performance for emergency readmissions for adults and children was "significantly below average", Mr. Wilmore's warning about having to make the methodology less transparent looks like a euphemism. We are dealing with some very murky waters indeed.
No wonder there seems to be some reluctance on the part of the Government to open up the whole episode to the public scrutiny that it needs. Before considering the effects of that ratings recalculation on the South Durham and other NHS trusts and the patients whom they serve, we need to examine the role of No. 10 Downing street.
The Health Service Journal broke its story on
"As I understand it, Mr. Milburn queried the star ratings for a number of hospitals, not just this one. In some cases, ratings changed; in other cases, they didn't."
What the Downing street spokesman did not say on
The extent of the Prime Minister's direct personal involvement remains unclear at present; although I wrote to him about the whole matter before Christmas, I have still received no reply. I trust that when the Secretary of State speaks in the debate, he will explain whether the Prime Minister expressed a view about the matter at the time. I trust that the Secretary of State will also tell us whether Mr. Stevens sent any reply from Downing street to the Department of Health in response to the e-mail that Sammy Sinclair, in the Secretary of State's office, had so helpfully copied to No. 10.
Let us turn to the consequences of the sudden re-rating of South Durham, because decisions about star ratings are not simply academic. The result of the last-minute upgrade following the then Secretary of State's intervention was to make South Durham eligible for a capital funding grant of £1 million. Very nice, too. But there is no such thing as a free lunch. That £1 million has to come from a finite pot of money—in this case, the £85 million available for three-star trusts. Less fortunate than South Durham was, for example, the George Eliot hospital in the west midlands, one of the six hospitals that had been awarded three stars in the list originally sent to the then Secretary of State on
I thank the hon. Gentleman for giving way. I am very interested in what he is saying, as it would surely be a good case to take to the parliamentary ombudsman so that she can investigate it.
I am grateful to the hon. Gentleman for that helpful suggestion. I had not previously thought of doing that but I shall give it consideration. I am sorry that I did not give way to the hon. Gentleman earlier on—[Interruption.] It was a good suggestion and he is being very helpful.
The doctors and nurses who work in the hospitals that were downgraded from three to two stars and the patients whom those hospitals serve may conclude that if they had been lucky enough to have one of Tony's cronies as their Member of Parliament they, too, would have enjoyed in 2002 the benefits that three-star status bestows.
My hon. Friend is describing a series of rather murky events, as he puts it, but will he tell the House if the same star-rating system applies to hospitals in Scotland, and whether the current Secretary of State will be protected from the same problems as have apparently affected his colleagues?
My right hon. Friend raises a very intriguing issue. Of course we all know that the current Secretary of State will answer today for what went on in northern England, in this case, in a way that he cannot answer for what goes on in Scotland. From what we read in some of the public prints, the waters in Scotland are at least as murky as those in South Durham.
One of the benefits of three-star status was described by the Health Service Journal in the same issue, which said that it bestowed
"a place on the starting grid once the race to form the first wave of foundation trusts got under way. Anybody who remembers the formation of the first NHS trusts in the early 90s will understand how valuable being in the vanguard can be."
We must remember that, back in July 2002, the then Secretary of State advocated a foundation trust model that was a great deal more robust, independent and exciting than the one that the Government, in the face of widespread rebellion from their own Back Benchers, introduced last November. The right hon. Member for Darlington would correctly have judged in July 2002 that the opportunity to be in the first wave of foundation trusts would be a great deal more valuable and advantageous than it eventually turned out to be.
I appreciate that the hon. Gentleman is developing his argument, and I am listening carefully to what he is saying. I have also studied in detail the Health Service Journal piece, which deals with the previous Secretary of State's intervention in respect of a trust in Basildon. Does the hon. Gentleman intend to develop his argument and set out why the Secretary of State also intervened in respect of Basildon, which does not seem to have a connection with himself or the Prime Minister?
The answer is that the same article in the Health Service Journal did indeed raise the issue of Basildon, but because I am concerned about the role of Downing street, as well as that of the Secretary of State, I am concentrating on what seems to be the particularly scandalous example of South Durham.
Can we take it that that is why the hon. Gentleman has not referred to the other seven trusts that have nothing to do with No. 10?
I am perfectly happy if, when the Secretary of State answers, he deals with the one trust with which I am particularly concerned, and we will take his answer as a proxy for how he might have answered on the other trusts that I could have mentioned. Indeed, if he is unable to answer in detail on South Durham, we have to assume that the waters are as murky in the case of all the others as well.
The Secretary of State has a clear choice this afternoon. He can opt—as I fear he may, given the tone of his interventions—for the cover-up route. He can bluster about how the system has been changed since 2002, how the role of the new Commission for Healthcare Audit and Inspection has been strengthened and how the Department of Health's involvement in awarding star ratings has been reduced, but none of that will alter the facts of the episode that I have just described. The words of the note sent by Mr. Wilmore to the Secretary of State on
Does my hon. Friend accept that what is not important is whether or not the Prime Minister or the Secretary of State made representations in connection with a particular trust? What is important is whether, if other hon. Members had made similar representations to the Secretary of State or the Department of Health, they would have received the same sympathetic acknowledgement of those representations and whether the decision made would be transparent in every way and be justifiable?
My hon. Friend is right. Of course any hon. Member on either side of the House is right to make representations about how their local NHS is treated. As my hon. Friend suggests, it is likely that representations from some hon. Members will receive more careful consideration than others. However, the circumstances in this case are indeed very much worse than in the situation that he implies. The Secretary of State and his senior officials were in possession of information about the conclusions arrived at by the methodology already agreed with the commission, and it pointed out that a hospital in which the Prime Minister and the Secretary of State had a direct interest had been downgraded. They chose to use that information in a manner that is wholly lacking in transparency to have those ratings reconsidered—I would say manipulated—to secure advantages for that local NHS trust that are denied to the trusts operating in the constituencies of many other hon. Members.
As I say, the Secretary of State has a choice today. He can become an accomplice of his predecessor. He can make himself complicit in this tale of ministerial interference, this case where the demands of low politics were put before the needs of patients and professionals. If he chooses that route, he will further undermine the integrity of the whole performance management process in the NHS because, if the people at the very top of the NHS, at the highest level in the Government, cannot be trusted to operate the system objectively, responsively and ethically, the public will have little confidence in the judgments that are reached.
I urge the Secretary of State therefore to take the alternative route: to announce today that all the relevant documents, e-mails, correspondence and other material will be made public immediately and to welcome any further investigation—whether by the parliamentary ombudsman, as Mr. Campbell so helpfully suggested, by the Health Committee, which may like to consider the matter, by the Public Accounts Committee or by any other body that decides to inquire into the matter, perhaps including the Health Service Journal. If the publication of that material indicates any wrongdoing or improper interference—either by No. 10 Downing street or by anyone at the Department of Health, including the Secretary of State's predecessor—he should establish a proper, independent inquiry into the whole matter that can be conducted swiftly and report to the House on what actually happened in July 2002.
Will my hon. Friend go further and say that hospitals, such as the Royal Bournemouth and Christchurch hospitals, that suffered as a result of the arbitrary action by Ministers should be compensated for the loss that they suffered?
My hon. Friend raises a very important issue on behalf of his local hospitals and his constituents. It is perfectly true that, if it appears that that trust suffered as a result of the manipulation of the ratings for political purposes, there is indeed a powerful case for saying that it should be compensated for those losses.
The local hospital in my constituency—the Queen Elizabeth hospital—has two stars. As my hon. Friend rightly points out, there are consequences for not getting the third star, but surely, given all the obsession with targets, stars and ministerial control from the centre, what we need is more local autonomy.
My hon. Friend is absolutely right. Of course local autonomy is a key element in our policies to improve the NHS and the lot of patients throughout the country.
No, I must conclude, I am afraid.
If the Secretary of State goes down the route that I propose, he will take the first step to redressing some of the damage that this rather shabby episode has inflicted. Opening up the circumstances that led to the re-rating of South Durham is necessary if public confidence is to be restored. I salute the work of Health Service Journal in bringing those facts into the public domain and the courage of those individuals who may have co-operated to help it do so.
In conclusion, let me remind the House that it is not only the Conservative Opposition who regard the star-rating system as deeply flawed. Jim Johnson, the chairman of the British Medical Association commented last July:
"Nobody should use star ratings to judge how well a hospital is doing. They measure little more than hospitals' ability to meet political targets and take inadequate account of clinical care or factors such as social deprivation. It is grossly unfair on staff working in low-rated trusts that public confidence in them is being undermined".
Imagine how the staff felt in the trusts whose ratings went down from three to two stars as a result of the exercise.
The Conservative party believes that the whole star-rating system should be scrapped. Its effect can be demoralising for staff and it does not provide valuable information for patients. It fails to acknowledge the complexity of the activities performed by the hospitals that it purports to judge. We shall return to the question of why the system is seriously flawed on another occasion. Today, however, we focus on one set of ratings that was unveiled 18 months ago and that has now been exposed as the victim of meddling by a Minister, which was perhaps carried out to curry favour with the Prime Minister—perhaps done even with the connivance or encouragement of No. 10 Downing street itself. I urge the Secretary of State to come clean on behalf of the Government, to publish all the documents that we need in full and to allow an inquiry to be conducted. I commend the motion to the House.
I beg to move, To leave out from "House" to the end of the Question, and to add instead thereof:
"notes that record investment in the NHS has to be linked to reform, and that this investment and the devolution of power to the front line require greater accountability;
congratulates the Government on its record of making the NHS more transparent through the development of performance indicators;
welcomes the Government's development of such indicators in consultation with patients and staff;
congratulates the Government on giving responsibility for NHS performance monitoring to the independent Commission for Healthcare Audit and Inspection (CHAI), which reports direct to Parliament;
and welcomes CHAI's commitment to developing new and more reflective indicators in partnership with representative bodies and the NHS itself."
This is a good old week for conspiracies. I thought at one stage that Mr. Yeo was going to demand an investigation by John Stevens into the murky deeds that he outlined. Let me make two things absolutely clear at the start. First, I—and all Labour Members—take allegations of this nature very seriously.
Because we do not treat them naively—I thank the right hon. Gentleman for his useful intervention. We are not naive about why such allegations are sometimes made. Today's Opposition day debate is not really about the failings of any Minister, the NHS, the star rating system, or NHS staff. We are under no illusion about why the debate was hyped up, as it was before the holidays. Incidentally, no regard has been paid to the two replies that have been given to the previous demands for an investigation, which amazes me, but I shall come back to that. Today's debate is about the failure of the Tory party—
For goodness' sake, let me at least start. I know that Conservative Members want to pre-empt every investigation—their leader pre-empted the Hutton investigation today—but rational people without malicious intent allow the other side to have a say before intervening. [Interruption.] Conservative Members do not necessarily benefit from shouting down a speaker either.
Today's debate is much more about the Tory party's failure to come to terms with one simple fact: the national health service has improved, is improving and will continue to improve. If I may use a metaphor, that is really what gets up its nose. [Interruption.] Opposition Members may say, "Rubbish", but we know that that is true, courtesy of the revelation of the former Opposition spokesman on health—now the half-chairman of the Conservative party—who was candid enough to tell us explicitly what his party's agenda was. He knows that if the improvements continue, and if people outside the House see them, Tory plans to undermine the national health service will themselves be undermined. His quaint words were:
"If Labour fix the national health service we are"—
I do not know what the final word beginning with "F" is—it is presumably "foxed". We know the Conservative party's agenda and why on every occasion it attempts to denigrate any achievements by people working in the health service, as it does with the case that we are debating. Although we take the subject seriously, we do not do that naively. The debate is a politically motivated personal attack to harm the national health service as well as the Labour party.
My right hon. Friend knows that I have been critical of the new health trust in Durham and the way in which it has been managed—I continue to have those reservations. However, three hospitals have been built in Durham since 1997, so does he agree that the situation is different from that under the Conservatives? A new hospital opened in my constituency last year, which replaced a hospital that was the old workhouse. There is a new £97 million hospital in the city of Durham and at Bishop Auckland. That represents a true record; the actual disgrace is the fact that the Conservatives never bothered about health care or investment in the county of Durham.
I entirely agree with my hon. Friend. The reality of the record is there for all to see. However, the Conservatives minimise any achievement in the NHS, maximise and magnify any failure—failures do happen—and put every success down to fiddling managers, cheating staff or, now, corrupt Ministers because they cannot stand to see the improvements. Let me turn to some of the details.
I shall give way if the hon. Gentlemen allow me to go through some of the narrative on this.
The motion attacks not only my predecessor as Secretary of State—I wish that the hon. Member for South Suffolk had read the motion, which was presumably written for him and tabled in his name—but targets, performance indicators and the whole system of evaluation. The Opposition consistently attack performance targets and indicators, but the targets have been absolutely essential to the improvements in the NHS over recent years. They have resulted in our drive that has achieved 14,000 more doctors, 15,000 more nurses and almost 400,000 more operations. They have resulted in a 10 per cent. reduction in cancer mortality for under-75s and a 23 per cent. reduction in cardio-vascular related deaths among people aged under 75. Speedier operations are reducing waiting times. The Government stand by the achievements and the way in which we managed them, which was partly through the targets and performance indicators that are attacked by the Conservatives.
I will give way after I have concluded my introductory comments. The motion for which the hon. Member for South Suffolk asks us to vote also attacks the transparency that we have introduced. That transparency is the basis for increased patient power. The wider availability of patient information, which for the first time since the formation of the NHS increases vastly the control exercised by ordinary members of the public over their health service, is dependent on that transparency.
The Conservatives also attack star ratings, which, for the first time, provide information about local health services and focus attention on what is important to patients and the public. None of their attacks arises by accident, and I shall continue to try to illustrate why they arise and go through the narrative of what happened during the events to which the hon. Member for South Suffolk referred partially, but not fully.
Will the Secretary of State assure the House that there will be no further use of terms such as "high-profile trusts" from anyone in his office merely according to the seniority or status of the relevant Member of Parliament? If our constituents think that health care is allocated according to the eminence or otherwise of their MP, it is an extremely serious matter.
I do not know whether that is a major question, but I shall treat it seriously although I have misgivings about whether it is actually serious. I take it that the hon. Gentleman has looked at the e-mails. If he checks them, he will see that the phrases were introduced not by anyone in the private office of the previous Secretary of State or, indeed, the previous Secretary of State, but by another official. That official does not work in the office of the Secretary of State or, indeed, Richmond House, but in Leeds. The phrase "high-priority" was shorthand and a completely innocent way of referring to several trusts.
Secondly, the phrase was not meant to define the trusts with major or high-priority politicians. If the hon. Gentleman reads the e-mails again, he will see that several other trusts are mentioned in that context—for example, from memory, the e-mail mentioned Great Ormond Street. When the former Secretary of State responded to it using the phrases and phraseology solicited from him, he referred to not one but nine trusts, one of which was subsequently moved up. That trust happens to be the local trust of a prominent Conservative Member, although she had nothing to do with the process. The interpretation of partial analysis of fragmentary so-called evidence by the hon. Member for South Suffolk is therefore utterly unjustified.
The issue is the political manipulation of the health service, and the right hon. Gentleman should be aware that his Department and his predecessor have a record in that regard, not least in my constituency and that of Laura Moffatt. Our hospitals were put together in a trust following an organisation programme agreed by the Department, which was unpopular in Crawley, as services were moved to my constituency. The right hon. Gentleman's predecessor ordered a moratorium two months before the general election in 2001 at a cost of £50,000 a month, as we established through parliamentary questions. The Department has refused to let me have the advice given by the trust, which was against the moratorium, both in principle and because patient safety was involved. If the Secretary of State is going to address the need for greater transparency in the health service, will he give an undertaking that I will get a copy of the advice that the trust gave at the time of his predecessor's decision?
There is a simple way, as the hon. Gentleman knows, to get information that is classified as confidential and privy to Ministers and their advisers. It is called an election, and such information is available to the elected Government, as the hon. Gentleman well knows because, as a former adviser to a Conservative Defence Secretary, he was privy for a number of years to information given in confidence to Ministers and on which assessments were based. Much of that information would have been of interest to hon. Members, but he was not expected to reveal it, and I am not prepared to reveal information that is confidential to Ministers and their advisers. That is how it will stay.
Order. The hon. Gentleman is trying to draw me into the debate. This is not a matter for the Chair, but a matter for debate.
Our debate is developing rather significantly. The Secretary of State accused me, I think, of relying on fragmentary evidence, but the solution to the problem is in his own hands if he publishes the documents. In relation to that request, he referred to parts of an e-mail, which did not appear in Health Service Journal, and mentioned Great Ormond Street hospital, which was not referred to anywhere in Health Service Journal. However, now that he has referred to that e-mail, is it not correct that he should place a copy of the full text in the Library?
If we are talking about the fragmentary nature of evidence, there was a glaring omission in the hon. Gentleman's own speech. I find it astounding that he failed to refer to the reply that the Conservative party chairman received from no less a person than the Cabinet Secretary—[Interruption.] If I could deal with the matter in hand. The hon. Member for South Suffolk may not share my opinions, but it would be helpful if he showed courtesy to the House.
The Cabinet Secretary, Sir Andrew Turnbull, sent a letter dated
"I have looked into the involvement of No. 10. As they have already made clear, the adviser covering health matters, Simon Stevens,"— to whom the hon. Member for South Suffolk referred—
"is routinely copied policy papers from the Department, and he was one of 65 people on the copy list for emails on the criteria for awarding star ratings. He did not intervene in this correspondence regarding South Durham nor any other NHS Trust. Nor did he raise the issue with the Prime Minister."
It is astounding that the hon. Member for South Suffolk did not share that information with the House. To paraphrase the Leader of the Opposition, we will take no lectures about allegations of a cover-up when the Conservative health spokesman has not even revealed that the questions he asked have been answered by no less a person than the Cabinet Secretary.
None of these attacks has happened by accident. The attacks are part of the Conservatives' unsuccessful attempts to undermine the efficacy and reputation of the national health service, and have nothing to do with discovering the truth.
On a point of order, Mr. Speaker. I asked the Secretary of State in my intervention a few minutes ago whether he would place in the Library a copy of the e-mail to which he referred and which is partially quoted in the Health Service Journal. Is it not a convention of the House, Mr. Speaker, that when a document is referred to and sections are quoted by a Minister that have not previously been quoted, it must be made available to hon. Members by it being placed in the Library?
There is a distinction, as an e-mail is not a document, so the matter is at the discretion of the Secretary of State. However, there is no requirement for e-mails to be placed in the Library. [Hon. Members: "That is new."] Order. E-mails are relatively new, which is why I have to make a ruling that previous Speakers did not have to make.
Let me make it clear that we are committed to providing patients, the public and, indeed, the House with credible, comprehensive and easily understandable information on how their local NHS organisations are performing. That is the primary purpose of star ratings. Our starting point—the premise that has been questioned in today's debate—is the Government's belief that the public need more information about how health services are working, both because their health is important to them and because public money pays for those services. It is precisely because we have asked the public to increase the money that they pay for the health service that we have increased public accountability and transparency through mechanisms such as the performance ratings.
That is why, in July 2000, for the first time ever, the Government introduced the concept of national health service performance ratings and the annual publication of information on all parts of the service. The rating awarded was to be based on an organisation's performance against a number of key targets such as waiting times and a wider set of "balanced scorecard" performance indicators. The hon. Member for South Suffolk said that he is troubled by three things. First, he is troubled that a Minister should respond, intervene or make queries about these issues. Secondly, he is troubled that a Minister should do so late in the process and shortly before publication. Thirdly, as I understand it, he is troubled that gradings were changed late in the ratings process. That is the essence of his concerns if we cleave away the conspiracy element.
I shall try to address those issues, and take the House through the development of the ratings process, which was pioneering, complex and difficult. Hon. Members should remember that it was not just about grading hospitals or trusts but about establishing and developing a grading system for the first time, which was as difficult as it was important.
The first set of ratings was published in September 2001, covering the performance of acute trusts in 2000–01. They were produced and published by my Department. We did not pretend then, nor do we yet claim, that those criteria were or are perfect in every way. Indeed, given the novelty of that pioneering approach to transparency, it could not be perfect at the first, second or even third attempt. We said so explicitly at the time.
We made three things clear at the very beginning: first, that the assessments were not perfect, but were based on the best available data and that we would aim to improve those data sources; secondly, that the data criteria—not the data, but the criteria for assessing performance—would also be refined and improved over the years ahead; and thirdly, that we would be working not only with trusts and the independent Commission for Health Improvement, but most obviously towards this end, within the Department of Health itself in the initial stages. In short, this was the establishment, development and refinement of an iterative process—one that was changing by the day and by the month, and which is still changing by the year.
That is the primary context that must be understood if we are to take a mature look at how things happened and what happened, rather than throwing it all aside and assuming that there is a great conspiracy behind everything that changes in Government and outside of Government.
The Secretary of State is placing great emphasis on the fact that the star ratings published in 2001 were the first time, in his view, that NHS trusts had been asked to account in public for their performance against pre-announced key performance indicators. Can he confirm that it was, in fact, my predecessor as Secretary of State for Health, my right hon. Friend Virginia Bottomley who introduced in the mid-1990s a system of publication of results by NHS trusts against key performance indicators, and that they were refined during my time as Secretary of State? It simply is not true to suggest that the star ratings published in 2001 were published out of the blue, with no previous experience in the health service or the Department of Health for the exercise on which they were embarking.
With all due respect to the right hon. Gentleman, we do not have a difference of principle, but the level of sophistication, complexity and intricacy of what we are doing now is light years away from anything that was done previously. That is not to detract from the fact that he and his colleagues at the time pursued that route for a while. I am not suggesting that they did not, but as someone who has borne the responsibility in government, he would be the first to accept that when one implements such initiatives in education or health, there is an ongoing discussion and debate.
Time after time, at Question Time and in debates, the Front-Bench spokesman prior to the hon. Member for South Suffolk got up and criticised me robustly and in some ways, perhaps, legitimately for some of the criteria that are used—non-clinical, non-medical criteria. I shall return to that point, because it is not only from one side of the House that we receive practical challenges to evaluate the criteria.
I am grateful to the Secretary of State for giving way again, and for his recognition that some groundwork was done in the 1990s. Perhaps he will reflect on the gap between the work that we did and the work that he and his immediate predecessor are seeking to do to enhance accountability in the NHS. There was an interruption between 1997 and 2001, and the Secretary of State might care to reflect that we would have made further progress if the incremental approach, which he is rightly espousing, had been allowed to develop through that gap in the process.
The right hon. Gentleman tempts me down a road down which I do not want to go. It is fair to say that as human beings in a complex world, the incumbent of my position during the relevant period would not agree with everything that I do, and I do not necessarily agree, on reflection, with everything that was done during that period. We will let the matter rest there.
Can my right hon. Friend clarify a couple of points for me? First, the Opposition are presumably suggesting that the trust should not have had its third star and deserved only two, which is a kick in the teeth for the enormous amount of hard work and energy put in by many people who work for it. Secondly, those on the Opposition Front Bench seem to want to scrap the entire ratings system and performance indicators, yet Mr. Dorrell claims credit for it. Perhaps my right hon. Friend could unravel the Tories' thinking on this important issue.
Will my hon. Friend allow me to make progress?
I was saying that the process was an iterative one—a process of development and refinement, and discussions were going on inside the Department of Health and externally, with trusts, among others. The system was still under development when the next set of ratings, covering performance in 2001–02, were published in July 2002. If we want to define the changes that were taking place, we should note that a broader set of indicators was used, more account was taken of the CHI reviews of clinical governance arrangements, and the ratings were extended to cover specialist trusts and ambulance trusts for the first time, and to include indicative ratings for mental health trusts. A great deal of change was taking place.
Again, put simply, the process of verifying data and refining the indicators to be used ran right up to the point of publication—the second element that worries the hon. Member for South Suffolk—precisely as it did the year before, which was the first year of star ratings. As anyone who has been involved in Government would know, when publishing large amounts of data it is quite normal for that to happen, particularly when the policy is in its early stages, when such large amounts of data are involved, and in this case, in 2002, when the release had been brought forward two months from September to July, putting greater pressure on the scrutiny and verification of the data and the final publication.
We were sensitive to the need to be able to justify publicly and to the organisations concerned changes in the ratings, especially when they arose from additional indicators that we were using for the first time. I have nothing but praise, in retrospect, for the amount of work that was done by our officials and civil servants. I hope that it was not meant in that way, but there is an innuendo in the remarks of the hon. Member for South Suffolk. The officials in the Department, who are people of great integrity and commitment, would not involve themselves in something that they perceived to be a political stitch-up. That has been clear to me in the many Departments in which I have worked. Let us reject that implication out of hand.
The Department was concerned to be able to justify publicly the nature of the criteria and the verifiable accuracy of the data. For that reason, and to ensure that the published information was as accurate as possible, NHS trusts were given the opportunity to comment on and to ratify the indicator constructions to confirm that they were correct prior to publication. In addition to the trusts, others were represented.
A significant number of NHS organisations—estimated at the time to be close to half of those who made representations during the ratification process—expressed concern with data quality on two proposed indicators being used for the first time in 2002. Those indicators were access to catering facilities, and information management and technology. If one were caricaturing the situation, as the Opposition sometimes do, one would define the criteria as 24-hour canteen facilities and 24-hour web-browsing facilities. During the consultation, a significant number of queries were raised about whether those were serious criteria.
Will the hon. Gentleman allow me to finish this narrative? It is extremely important.
It was clear that those indicators were not of a high enough quality and that the issue could not be resolved in time for publication of the ratings. I am advised by those who were involved as officials at the time that even if the timetable from the previous year had applied, there would not have been time to improve those particular indicators. They could not, therefore, be included in a refined and improved form in the final set of indicators. They could, of course, be removed.
I am grateful to the Secretary of State for giving way. He has described the discussions with trusts, and presumably the Commission for Health Improvement, that led to the submission to the then Secretary of State on
A little trust from the hon. Gentleman would be welcome. I am taking him through a narrative. I started in one year and I am moving chronologically. Consultations and discussions did not stop on
Let me make some headway; I shall come back to the issue.
The change to which I have referred and which others made during the final weeks inevitably had an impact on the ratings. Some trusts benefited, while others lost out. Another part of the information that was not mentioned earlier is that, after
No; this is a crucial point, and I make it in response to a demand that was made constantly from the Opposition Front Bench. After
The Opposition are today asking for another inquiry into the matter. As I pointed out, one of the two chairmen of the Conservative party requested an investigation from the Cabinet Secretary. The Cabinet Secretary also took it upon himself, I think legitimately and with due diligence, to ask the permanent secretary in my Department to conduct an investigation. He wrote this morning to the chairman of the Conservative party. I am surprised that the hon. Member for South Suffolk has not been informed by his party chairman. [Interruption.] Apparently, he has now received that information. To be helpful, I shall read out just two paragraphs of the letter, which I shall place in the Library. I quote the permanent secretary:
"Ministers were, quite properly, involved in the process of developing the ratings system—which was one of the key commitments of the NHS Plan—and in preparing the announcement of the results for which they were Departmentally responsible. As part of ensuring that changes to the ratings of individual Trusts could be justified by reference to robust evidence, officials rightly highlighted individual cases to Ministers and they, legitimately, raised questions about other cases, including South Durham. One category of cases highlighted in this way—which included at one stage South Durham—were 3 Star Trusts at risk of losing a star. Naturally Ministers wanted to be reassured that any change in the ratings was a result of a genuine change in performance."
He begins the next paragraph thus:
"The ratings of some of the Trusts under discussion at this stage of the process did change as a result of the changes to the methodology which I have described. In other cases they did not."
Here is the important point:
"I am satisfied that no changes were made to the methodology in order to manipulate the rating of any individual Trust. I am also satisfied that political considerations played no part in any of these decisions."
Let me repeat that sentence:
"I am also satisfied that political considerations played no part in any of these decisions."
I shall wait to see whether, having attacked trusts and managers and referred to cheats and fiddlers in the NHS, those on the Opposition Front Bench are now about to attack the permanent secretary at the Department of Health and Sir Andrew Turnbull at No. 10 Downing street. The fact is that the situation with regard to the crucial question could not be clearer: no political considerations were involved. In view of the relevance of Sir Nigel's letter to the motion, I have obviously asked for a copy to be placed in the Library.
There is nothing unusual about changes to provisional star ratings status occurring prior to publication. We could look at many trusts and see changes in the weeks beforehand. Given the importance of the data, we recognise that we have to ensure that we continue to progress the independence of the system. I can tell the House that responsibility for continuing to ensure a robust system of performance ratings for the third year of publication and for July 2003 was passed to the independent Commission for Health Improvement in 2002. The new Commission for Healthcare Audit and Inspection will take over responsibility for the ratings process from April 2004 and will publish the 2003–04 ratings as part of its annual report to Parliament this summer. It is independent of government and will continue to ensure the integrity of the ratings.
In short, within three years, the Government have developed the data on which to base the performance and published them, and we have now made sure that responsibility for the publication of the data and criteria will be completely independent of government. In contrast, we know from the motion what the Opposition believe in. The motion calls for greater transparency in the calculation and publication of performance indicators throughout the NHS and goes on to express concern that these indicators might be used by people to indicate performance. If we check that position against the Opposition's actions, we see that it is difficult to find a bigger piece of hypocrisy, even in the Conservative party. Its actions in every conceivable area belie what it is demanding in parts of the motion.
I am grateful to my right hon. Friend for again giving way. The history of star rating that we have been given this afternoon has been interesting for the anoraks, but may I draw his attention to the fact that the abolition of the South Durham trust and the transfer of most of its management, including the chief executive, to the new County Durham trust raises issues that need to be addressed, including concerns among my constituents and others in Durham? For example, last week, the accident and emergency department of the new University hospital, Durham, was closed to new admissions because of lack of beds. Instead of talking about historic star ratings today, we would have been far better off discussing the investment that has gone into Durham and the management of the NHS trust there.
I agree entirely with my hon. Friend. As he and other colleagues have pointed out, the Opposition are attacking trusts for the good work that they have done, and not only those in Labour areas are affected. Interestingly, one of the results queried by the previous Secretary of State was that of the West Suffolk hospital trust. I recommend that the hon. Member for South Suffolk listens, as the issue has some relevance to him. That trust serves the constituencies of three hon. Members, all of them from the Opposition Benches. Indeed, it includes South Suffolk, the constituency of the Opposition spokesman who opened the debate. Presumably, a sub-plot of the conspiracy is held to be that the previous Secretary of State was doing his damnedest to ensure that the hon. Gentleman's trust was moved up the ladder as well. That illustrates the ludicrous nature of the conspiracy that has been proposed today. It is the usual thing from the Conservatives. That is why they claim that nothing is getting better in the health service, that the NHS cannot improve, and that if it does improve, it is all a fiddle or a conspiracy. That is why they denigrate and diminish everything that is done by the 1.3 million people who constitute the biggest army for good in western Europe—the staff of our national health service.
The Conservatives know that slowly but surely NHS performance is improving. They know, equally surely, that the public and the electorate will reject their attacks on the NHS and, in doing so, will reject their failed, dogmatic policies—just as we should reject this cynical, opportunistic and politically-motivated motion and vote for the amendment that was tabled in my name and that of the Prime Minister.
This is proving an interesting and useful debate. In his response, the Secretary of State answered some of the questions, but gave rise to several others that I hope that the Minister will be able to address. Not long ago, on another Conservative Opposition day, we debated the target-setting culture in the national health service and the way in which it provokes changes in behaviour in the NHS that are not always those that are intended—indeed, poor target setting can be corrosive of NHS morale and lead to perverse outcomes.
During that debate, we focused on the way in which targets and performance indicators can distort clinical priorities and lead to unintended consequences; today, we are focusing on the important exposé in the Health Service Journal and the information that it helpfully brought into the public domain. I hope that the Secretary of State will agree, even at this late stage, that that process should go further to ensure that we have all the information about the star ratings process and the build-up to its publication in 2002. A few bits have been teased out today, but there is still more to come.
There is a fine line between what one might call the fine-tuning, data checking and reality checking of performance indicators and star ratings and the fiddling of figures. On the basis of the evidence that was published in the Health Service Journal before Christmas, one could conclude that that line has been crossed. I want to return to the letters that the Secretary of State mentioned, because they raise further questions.
The basis on which the 2002 star ratings were calculated was changed—that is accepted. The Secretary of State tells us that that is part of an ongoing, iterative process. They were changed at the last minute, and the change had a real effect. Nine trusts went up from two to three stars and six went down from three to two stars. As a consequence, those six trusts were, in effect, robbed of up to £1 million each for service improvements that would have been available to them had they been three-star trusts. In addition, they were denied a range of modest, but nevertheless welcome, freedoms and flexibilities that are part of the star rating system.
The Health Service Journal documents the e-mail exchanges between the office of the former Secretary of State and the head of the performance development unit in the Department, Mr. Wilmore, who warned on
"Unfortunately even if time allowed it, further revisions to the methodology to promote these trusts would inevitably lead to other individual results we had not expected, as well as making the scoring system more complicated."
The Secretary of State has laboured the point that so far the debate has focused on South Durham. That will not be the thrust of my argument, because the key question is not whether the methodology was changed to fix it for one trust, but whether it was changed inappropriately, at the last minute, with unforeseen consequences for a number of trusts that hitherto would have had three stars and all the benefits that flow from that. That is why Basildon and Thurrock general hospital was one of those mentioned in the official's report to the then Secretary of State. He said:
"Adjustments to the methodology would have to be severe to move the trust to three stars and would inevitably demote other high profile trusts in the process."
In his response to Mr. Yeo, the Secretary of State said, effectively, that the main changes to the methodology concerned catering services and information management. Yet the paper that was sent to the Secretary of State at the time, which was the basis of the article in the Health Service Journal, says that the reason why Basildon and Thurrock general hospital was not going to secure a three-star rating was because of the patient-focused element in the methodology, and specifically because of the results from the patient survey. I wonder, therefore, how that methodology was changed to reflect a high three-star rating for that trust in the final run of the star rating calculations for 2002. The Secretary of State has not yet dealt with that.
I hope that this will be helpful to the hon. Gentleman. As regards his suggestion that things were done late, they were done continually; some were done late. My hon. Friend the Minister will respond to that. The key word in his argument is "inappropriate", because we believed then, and believe now, that the changes were appropriate, and such changes continue. It is important to remember that changing one or two indicators will not affect the majority of trust results, but it will inevitably affect some—not only one—because the star rating system uses the relative position of trusts against a wide range of balanced scorecard indicators to help to distinguish between two-star and three-star trusts. That means that a trust's position can be improved or worsened by changes to the indicator scores of other trusts. That is the essence of the relativity effect whereby changing one indicator can affect a series of trusts, which, in turn, affects other trusts because of their relative performances.
I am grateful to the Secretary of State. That implies that the removal from the methodology of catering and information management did constitute a severe change in terms of that official's advice and warning to the then Secretary of State on
Mr. Wilmore asked the Secretary of State's office for comments by
"Secretary of State would also identify South Durham as a high profile Trust"— we heard earlier that the Secretary of State's office had used the words "high-profile trust"—
That further suggests that there are some low-profile trusts. I hope that my hon. Friend agrees that there should be no such trusts. A quite different set of categories, which appears to be political rather than based on any clinical need, is being introduced into the discussion.
My hon. Friend makes an important point. I hope that the Minister will accept that "high-profile trusts" is an unfortunate use of terminology that should not have crept even into an e-mail that was not expected to become as widely disseminated as it has.
In response to the e-mail, Mr. Wilmore stated:
"Alterations to the methodology have been made, resulting in the changes to individual trusts that were requested. This makes the scoring methodology more difficult to explain and less transparent."
"An explanation of the revised methodology has yet to be written up."
Will the Secretary of State put into the public domain the detailed write-up of the methodology that followed the further recalculation that led to that exchange of e-mails? That would be a useful document in terms of understanding what the Secretary of State has said to me and to the hon. Member for South Suffolk.
Mr. Wilmore then notes that Basildon and Thurrock and South Durham
"now receive a three-star rating".
His paper offers no further explanation of why South Durham was originally downgraded from three to two stars and does not attempt to answer the Secretary of State's perfectly legitimate question about why that change occurred. It will be interesting to have the answer so that we can be clear about the way in which the methodology and other processes that contribute to a star rating were affected to produce the outcome in 2002.
We also know that the exchange of e-mails was copied to the Prime Minister's health adviser and we are told that the relevant e-mail was not acted upon. Does that mean that the e-mail was not read? Given that the Prime Minister's health adviser apparently routinely receives copies of e-mails between Health Ministers' private offices and the Department, what does he do with them? I am told that he is dynamic, proactive and hands on. The nature of e-mail drives people to respond and I am therefore puzzled that the health adviser did not respond and possibly chose to open it and do no more.
A question, which I hope the Minister who responds to the debate can answer, about the Prime Minister's knowledge of events has not been asked. It is not whether his adviser, on the basis of the e-mail exchanges, notified him of the specific anxiety about the high-profile trust, but when he became aware of the South Durham star rating. It would be useful to have that specific piece of chronology.
Since the publication of the e-mail trail, the official line has comprised two elements. First, what happened is part of the normal process of signing off the star ratings, which would be subject to adjustments and corrections every year as part of the iterative process. Secondly, the responsibility for finalising and publishing star ratings is now that of the Commission for Healthcare Audit and Inspection—as if that makes okay anything that was inappropriate in the past.
The unofficial line that Mr. Milburn has taken is that it is all a load of tosh. I hope that that is a parliamentary term and that I can therefore use it. How can it be tosh for a senior official to warn the Secretary of State that changes to the method of calculating the 2002 star ratings made them more difficult to explain and less transparent?
I want to ask a few questions of the Minister who will reply to the debate. First, why were the changes made so late in the day, after they had been reality checked? That is especially relevant to the trusts that were part of the system in 2002. Secondly, why were the warnings of the head of the performance development unit about the difficulties of making the changes at such a late stage ignored? Thirdly, what changes to the methodology led to such a big shift in the star ratings but did not affect the trusts with zero star ratings? Again, that relates to the detailed write-up of the methodology that I requested earlier. I hope that the Secretary of State or the Minister who replies to the debate can provide that.
The handling of the 2002 star ratings must give rise to questions about that of the 2003 ratings. In 2003, for the first time, the Commission for Health Improvement was responsible for publishing them, but it would be strange if the Department had not maintained a close interest in the way in which CHI was taking the work forward. As well as publishing all the Department's material that was relevant to the 2002 star ratings, will the Secretary of State undertake to publish all papers and e-mails about the methodology and weightings for each element of the 2003 star ratings, in the interest of restoring public confidence in the star ratings system, which he clearly wishes to achieve?
The way in which the 2002 star ratings were handled raises wider questions about performance monitoring in the NHS and the way in which data are collected and published. In November last year, the Nuffield Trust published its mid-term review of the Government's progress in delivering improvement in the NHS. The report was positive—I am sure that that pleased Ministers. However, there was a sting in the tail. One of the report's authors, Professor Sheila Leatherman said:
"There are significant data and analytic weaknesses in the NHS which mean carrying out a comprehensive, robust, definitive, transparent and defensible assessment is impossible.
The unrelenting and distracting problem of inconsistent and highly contested data throws the whole of the quality agenda into a confusing fray."
Until the data are collected, audited and published independently of the Government, how can the public have confidence that their money is being spent wisely?
In its report, "Performance Indicators: Good, Bad and Ugly", the Royal Statistical Society calls for performance indicators to be accorded the same status as national statistics. In other words, the process should be clearly independent and at arm's length from the Government, to an even greater extent than the new Commission for Healthcare Audit and Inspection allows.
The report detailed several pitfalls that we discussed in the Chamber when we previously considered target setting, not least that performance measurement can create unintended consequences and lead to manipulation of data, gaming or fraud by service providers. Indeed, the Audit Commission and the National Audit Office found that in reports that they published last year.
Performance measurement changes behaviour. The Royal Statistical Society stated:
"Behaviour change is a factor because no performance measurement scheme can be viewed in isolation from the incentives—designed or accidental—that exist alongside it. Designed incentives often take the form of targets, and set of consequences associated with performance. If the assessment of management functions in the NHS depends centrally on whether explicit waiting time targets are secured, then this can affect such things as patient handling among health care professionals."
In other words, what gets measured gets done.
I am about to deal with the review of data collection, about which the Secretary of State told the Health Committee. [Interruption.] I shall answer the hon. Gentleman's point in my own way and in due course, if he does not mind.
The Secretary of State told the Health Committee that the Department was reviewing its data collection with a view to rationalising what it collects. The NHS confederation has expressed concern for some time about the burden of reporting requirements on the NHS. In December, after a year of consultation and discussions, the Confederation published its report, "Smarter Reporting". The report found that more than half the information requests from the Department were perceived not to be useful for managing NHS trusts, either because it asked for duplicate information or because the data were of questionable value.
The survey also found that a quarter of returns that the Department required were wholly or partly duplications. Much could therefore be stripped out of data collection without materially affecting the value of the data that the Department is currently gathering. Simply cutting back the duplication would make a difference. Rationalising data collection helps to improve the quality of the data that are being collected.
In the conclusion to its report, the NHS Confederation warns that the exercise that the Department is currently undertaking entails a risk of losing the value of data collection in the existing system. I hope that the Secretary of State can assure us through the Minister who responds that an extensive dialogue is going on with the NHS Confederation and others to ensure that we get the best data collection and fill the gaps when that will add something to our understanding of service development, policy development and performance in the NHS.
Liberal Democrat Members will support the Opposition motion because we believe that there is a need to bring into the public domain information, which is not there, about what happened in 2002. We are critical of the way in which the star rating and performance management system has been rolled out in the past few years. It is clear from the events that surrounded the 2002 star rating that the process and reporting have damaged the credibility of the star ratings system. Indeed, they have dealt it a fatal blow. How can the public have confidence in the current star ratings system? What messages have been sent to NHS staff, especially those in trusts that lost their third star because of the recalculations? They were told one minute that they were an excellent trust, then suddenly that they were considered middle rating. What message does that convey?
We will support the motion. The NHS is improving, but we need a reliable system that enables us to know that it is improving. That currently does not exist. Until it does, we cannot support the star ratings system.
Whenever the star rating system is put under pressure or attacked, I feel the need to make a contribution in its defence on behalf of my constituents. It is the first system to allow people in my constituency to be heard on the subject of the performance of their local hospital. All my constituents, half of whom use St. Helier hospital, knew before 2000 that it was not up to scratch, that it was too dirty, and that the services provided were not good enough. Contributions from me, as the local Member of Parliament, and from the community health council, and missives presumably from the Department of Health all had no effect. The then chief executive carried on and refused to listen to the problems that existed. The only thing that broke that logjam was the star rating report that roundly, fairly and justly gave St. Helier hospital no stars.
That marked the beginning of the improvements in my local hospital. It also meant that there was perhaps a distortion in the allocation of funds, because funds came to that hospital for the first time for the improvement of its Nightingale wards and its standards of cleanliness. For the first time, the hospital examined how elderly people in the geriatric wards were cared for, and whether they were being provided with food but not fed. Elderly people were actually starving in the wards. The fact that the star rating system can achieve those improvements, and that it allows the public to know that the Government know what they know, is essential.
The system has led to enormous improvements in the services that people in my constituency receive today. I am not saying that St. Helier hospital is a perfect institution, but it is improving, and everyone there knows that it will be reviewed on an annual basis. That improvement must continue.
I disagree with the hon. Gentleman. People know that the hospital had a zero star rating. The rating was immediately understandable and one that people generally accepted. The then chief executive decided to resign and was replaced with another chief executive who achieved incredible improvements and has now been promoted. I wish every luck to the new chief executive in carrying on in the same way.
St. Helier is far from perfect and it needs to continue to improve. I am glad that the star rating system is there to help it to continue that improvement. I should like to finish by quoting from a letter about St. Helier that I received today from a constituent:
"I was admitted to the hospital two weeks ago as an emergency admission to A & E and then to both Ward C6 and then Beacon Ward. I was most impressed by the kindness of all members of staff during the day and nights, their attention to correct hygiene procedures at all times, and the doctors who with their regular visits make you feel special by keeping you informed in your progress. I would also like to thank the dinner and tea ladies and cleaning ladies and men, who were always cheerful and willing to help in any way they could. Words cannot express my gratitude to everyone involved in my recovery and their obvious pride in their work and their teamwork, which was second to none. Please pass on my thanks to everyone involved in my recovery."
This is about people's health improvement, and the star ratings have led to Mrs. McNaughton having a much better experience at St. Helier than she would have done prior to 2000.
I should like to pick up on the theme pursued by Siobhain McDonagh. My very recent experience of what star ratings have done, and of the state of our NHS hospitals, has been quite appalling. I believe that the focus on nationally set targets skews the way in which decisions are made about resource allocation in hospitals in order to meet targets and to get the extra finance so as to go up the star ratings system.
I want to make it clear that I am speaking about a one-star hospital not in my constituency but in the home counties, to which an elderly lady relative of mine was recently admitted. She was very frail and had a fractured neck of femur—a common problem incurred when elderly people fall. She was admitted to casualty and I was anxious that she should not have to wait on a trolley for a long time. I was pleasantly surprised, therefore, when she was admitted to a ward within a few hours. I was told that she would be operated on the next day. Anyone with any medical knowledge will know that it is important to operate on a fractured neck of femur within a maximum of 48 hours, whatever the person's state of health or age. As is the normal custom, my relative was designated nil by mouth, but she went on being nil by mouth for five days, until eventually I threatened to go to the press unless she was operated on.
I shall not go into any more detail about the individuals concerned in this case because I am pursuing a formal complaint with the hospital concerned. The reason why I am raising it here is to point out that, in order to meet the elective surgery targets set by the Department of Health, that hospital has a long waiting list of former cases on an ongoing basis. That is where the skewing of targets and resources causes extreme detriment to patients. Hospital surgeons tell us that it is not uncommon for them to have 30 trauma cases waiting, but that their hospital management will not open up a second theatre over a weekend to deal not just with the existing backlog of trauma cases but with the increasing number of accident and emergency cases coming in. As someone who has worked in an operating theatre, I fully understand the dilemma of the doctors and nurses in our health service who, when faced with a road traffic accident admittance, for example, have to deal with some of those cases before they can deal with the fractured necks of femur or the trauma cases sitting on their wards.
The one-star hospital in question here had met the Government's target of not having people sitting round in casualty for more than three hours. It had admitted the patient to a bed, but had not had the resources to deal with the number of trauma cases that such a catchment area naturally has. My investigations have shown that this is not a one-off. In fact, I intend to pursue the matter to find out just what the state of trauma surgery in our hospitals is, whether they have one star or three.
Having been through that experience, when I hear Ministers talking about data, systems and civil servants, it all seems very remote from the day-to-day experiences of people up and down the country who are faced with a health service that, frankly, is not delivering. This is not just about what we used in the old days to call cold surgery—elective cases, as they are now called—painful though it is for people waiting to have a hip replaced. Of course we want those people to be treated as quickly as possible. When targets are introduced, they start to skew the service for others, for whom life and health are going to be critical. There is something seriously wrong with the target system that now exists, particularly in relation to surgical cases in hospitals.
I entirely share the hon. Lady's concern. It is completely unacceptable that an elderly lady with a fractured hip should wait five days for an operation, and I would welcome further information on how that was allowed to happen, and on what could be done to prevent it from happening again. This raises the important point, however, that unless we measure what is going on in our hospitals, we have no way of improving them. Does the hon. Lady not agree that the only way to ensure that the health service is as good for her constituents as I hope it is for mine is to ensure that the investment goes in to improve it year on year and that we introduce changes and improvements to ensure that the money is well spent and invested, and used directly to improve patient care. We must have information before we can measure those outcomes.
I am not saying that performance indicators and information are unnecessary. They are important management tools in any function, and particularly so in the NHS. I am not complaining about that. I am saying that, when targets are set by Ministers in Whitehall, it restricts the flexibility that hospital clinicians and managers have at local level, in terms of what a hospital's priority should be on any given day or week. Therefore, in hospitals such as the one I have mentioned, which has a one-star rating—I hope that Members on both sides of the House, having heard my experience, will say, "No wonder it has a one-star rating"—where the real difficulty was that surgeons were asking to open up second theatres to deal with trauma and were being denied them by the management, the management clearly had to prioritise its resources and money to make sure that it met targets in elective surgery and other priorities that are not being decided at a local level. Meeting many of those targets is locked in to the star system, and we have heard arguments today about the funding that hospitals receive.
Of course, nobody expects poor performance to be rewarded, but what choice is available to a patient who lives in one of those areas? It would be nice if all hospitals—in accordance with the experience of Siobhain McDonagh—were seeing an improvement. I have not seen an improvement, however, in a situation in which managers are told what their priorities should be by people who have no clinical responsibility. When we are dealing with real cases face to face rather than talking about statistics as we do in this place, and when real people whom we know and love are affected, that brings home much more clearly how wrong the current system is in terms of control from the centre that overrides what doctors believe should be the priority in a particular hospital. Mr. McCabe shakes his head, but when there are people who will die, and doctors know that they will die, doctors ask for second theatres to be opened. My experience when I worked in a theatre under the previous Labour Government was that such theatres were opened up. At weekends, there was always a standby team for a second theatre to be opened up. Things have not got better; they have got worse.
Obviously, it is difficult for us to discuss the case that the hon. Lady raises, as we are not privy to all the details. Does she accept, however, that it is not self-evident that targets were the problem, but that the hospital concerned either did not have adequate resources or was not managing its resources properly? Had the hospital made available resources for the case she mentioned, I presume that it would have had to take them away from another one. Targets relate to real clinical need, so that would have meant other people waiting for operations. The case that she raises does not therefore attack targets but points to the need for additional resources.
In terms of prioritising resources for surgical cases in a general hospital, trauma cases would be high up, at the top of the list—they would have to come higher than elective surgery because they are life-and-death cases. In relation to the individual case that I described, it was not a one-off case: the hospital had a long trauma list that appeared to be ongoing, and apart from the case of which I have personal experience, 29 other people were in similar situations. In terms of resources and a surgical budget, priority must be given to the trauma surgical budget over the elective budget. If one is subject to elective budget targets, and to achieving stars by meeting elective targets, or to having financial penalties in the next financial year, as some hospitals have experienced, that is wrong. It is wrong not from a management or systems point of view but from the point of view of the people who live in that area and who are dependent on that one hospital, to which they go if they have an accident.
If people have elective surgery, even under this Government, certain flexibilities exist whereby they can try to choose which hospital they go to and who operates on them. If they have an accident and are taken to hospital in an ambulance, they do not have a choice. What I am saying is that if people are taken in an ambulance to an accident and emergency department and they need surgery following that admission so that they are stuck with that one hospital, that area of surgery should be given high priority and should not be subject to problems that relate either to how the budget is spent in other areas or to the need to meet elective surgical targets.
I wanted to raise this issue because I am worried about the number of deaths in this country as a result of fractured neck of femur, particularly among the elderly. I am concerned that elderly people who are admitted on that basis are shunted down the list purely on grounds of age. That is an area of health care that needs investigation, not just because of my personal experience but because I am concerned that this is a widespread problem throughout the country and needs to be addressed as a matter of urgency.
The truth is that there are two parts to today's debate. The first part—the only one to which Mr. Yeo referred—is the Tory agenda. It has none of the "I believe" and the "Be positive" in it. It says, "Get on the negative and hit it hard." The Tory party's strategy is to undermine the health service at every turn and at every opportunity, and it must persuade the public that the health service is failing. That is the only point at which any Tory policy begins to emerge.
Coupled with that, we are starting to see a new trend in Tory performance. Yesterday, the shadow Secretary of State for Transport used the pilots' trade union as the bulwark for her argument. Today, the Tory health and education spokesman used the doctors' trade union spokesman—a gentleman whom I believe is a consultant at a one-star hospital, so, clearly, he has no vested interest—as the bulwark for his argument.
The other part of the Tory agenda is clear. The Tory party is haunted by the sleaze that bedevilled the last Tory Government, so it has decided that the easiest way to defuse that is to apply to all politics and all politicians the taint that they cannot be trusted. Today, we heard a twin strategy to undermine and attack the health service at every opportunity, and to attack the people who work in it and who are doing their best to drive up standards and performance and to give the best care to those most in need—to attack, condemn and denigrate at every turn.
Simultaneously, the Tories are attempting to persuade the public that the way to deal with sleaze is not to make the Tories account for what they did and for why so many of them ended up in the courts and jails but to say that all politicians are liars, that all politicians try to distort, and that all politicians try to manipulate solely for personal gain.
I am happy to give the right hon. Gentleman a list of former Conservative Cabinet Ministers and serious politicians who ended up in court and in jail. I am happy to assert that if that is what he wants. My point is that the Conservatives have a twin strategy: first, to undermine and denigrate the health service—
I think that the right hon. Gentleman has a hearing problem. I did not assert that at all. I asserted that the Conservative party has a problem with sleaze dating back to the previous Conservative Government, and its political strategy to try to deal with that is to try to smear everyone else. I repeat that. I am not surprised that he does not like to hear it, but it is unfortunately the case, and he will hear a lot more of it if the Conservatives persist in their current performance.
Does the hon. Gentleman accept that the basic text for much of today's debate has been the article that appeared in the Health Service Journal, and which was produced by its own, well-respected journalists? Is he trying to tell the House that that publication is an organ of the Conservative party, because I am not aware that it is?
I want to turn to the second aspect of the debate, which is the effectiveness of indicators, the need for greater transparency and the question of whether the way in which trusts operate is distorted—a matter that Mrs. Browning raised. I am not at all convinced that the indicators are ineffective. I would be the first to accept that they can always be improved, which probably explains why they have been revised at least three times already. As I understand it, acute trusts are currently using 44 indicators. Some 13 are the same as the originals, 23 are broadly similar and there are eight new ones. That has happened because in talking to the trusts and taking account of the other clinical governance exercises that have taken place, the Commission for Healthcare Audit and Inspection has been responding to demands for change. It has been told that some of the indicators are not particularly effective, are rather time-consuming in terms of the way in which the data are processed, and do not deliver that much. As a result, it has been asked whether they can be got rid of or changed, and whether other factors that have not been taken into account could be included. That seems a sensible approach.
I am constantly told that the indicators are useless, but it is important to bear in mind what young and adult in-patients say about the quality of care, the level of safety and the degree of co-ordination. Cancelled operations are a good indicator, and clinical negligence is another important factor that I would want to know about if I was going to a local hospital. The number of deaths following heart bypass operations might also offer a reasonably good clue as to how the hospital in question is performing. One might also want to take into account deaths following non-elective surgical procedures. Emergency readmissions following discharge are also worth knowing about, as are readmissions following discharge in respect of fractured hips.
My hon. Friend makes a very important point. Opposition Members say that it is their policy to scrap star ratings, thereby denying us, presumably, the information that he has so eloquently given on these extremely important indicators. Such knowledge would certainly influence my choice of hospital if I needed an elective operation.
My hon. Friend is absolutely right. I am not saying that the system is perfect. I have never heard a Minister say that it is perfect, and nor did the Secretary of State claim that today. What we are saying is that we have a method of measuring, and of giving trusts and the public an idea of what is happening. That is important.
It is not possible to make a choice in respect of non-elective surgery, so what does someone do if they are in an ambulance following an accident and the hospital to which they are being taken for treatment is terrible?
The hon. Lady knows as well as I do that, in that circumstance, the average individual would not be in much of a position to do anything. My point is that we have indicators that allow us to measure performance, and to try to drive it up.
The hon. Gentleman has indeed been generous, and I am grateful to him for giving way again. I want to correct what might otherwise be a misapprehension on his and his colleagues' part. He asks us to look at the motion, but if he does so he will see that its purpose is to stop "excessive reliance" on indicators, not to remove the information that patients need. But star ratings are an essential part of that excessive reliance, and as my hon. Friend Mrs. Browning pointed out, they are part of a system of targets that leads to distortions.
I am grateful for that intervention. If the Opposition spokesman had discussed the rest of the motion during his speech, rather than dwelling on the first four lines, perhaps we would not have needed that intervention.
The indicators are owned by CHAI, which reports to Parliament, so they are hardly open to manipulation by Ministers. And what of the effect on trusts? We are told that the indicators distort the allocation of resources and inhibit the independence of professionals and managers. I asked my local acute trust how it makes use of them, and whether they in fact constitute an onerous chore. It gave a couple of examples that are worth pointing out. It examined the time involved in accident and emergency situations, and concluded that it had to change some of the doctors' practices. For example, more weekend work for consultants was mentioned. That may be a real drag in terms of time spent on the golf course, but sometimes such changes have to be made. It also examined some of the cancer indicators, and although it measured some progress, it discovered specific areas in which there were capacity problems. As a result, it knows that spending must be skewed to address that issue. Frankly, cancer sufferers will be delighted, rather than saddened, to hear that. Funnily enough, the trust also noticed that it has to do better in respect of people's complaints, an issue to which the hon. Member for Tiverton and Honiton referred earlier. It wants to deal with complaints openly and transparently.
These indicators are not perfect, but they do give us and the public some indication of what is happening. In terms of their development, there is interaction between the trusts, the patients forums as they come on line, and CHAI. We also know that they are used in a practical way by good trusts that want to improve, in order to move matters forward. The choice is between sweeping that away or coming up with a credible alternative. When Opposition Members come up with a credible alternative, I shall listen to it seriously.
I want to begin by making it clear that I am in favour of the principle that better management of the health service, better care for patients and better use of resources will be achieved if we require health service institutions to publish evidence of how they are performing against key performance indicators. I embrace that principle wholeheartedly, and for some fairly conventional reasons. I do not believe it right that this public service should be managed in secret, and that the people who pay for it and use it should be unaware of its performance. Nor do I believe that special rules in this respect apply to the clinical professions. In respect of NHS institutions, it is just as important that evidence of clinical performance be published, as well as non-clinical performance. It would be strange if I thought any different, because as I said in an intervention on the Secretary of State, that was the route that we took when in government. It was my immediate predecessor as Secretary of State, my right hon. Friend for South-West Surrey (Virginia Bottomley), who introduced the principle. I developed it, and I share in the implied criticism offered by the current Secretary of State in respect of his predecessor, Mr. Dobson, in that the policy was not developed during the years immediately after our leaving office.
It is not the principle of the Government's requirement that the NHS publish evidence of its performance that is wrong; what is wrong is the way in which the Government develop that principle in practice. I want to go through some of the reasons why the Secretary of State finds himself in such deep water as a result of the story published just before Christmas by the Health Service Journal. The story is powerful evidence that the Government are failing in practice to pursue the good principle that the NHS should be seen to be accountable. Why are they so failing? The first fact that anybody introducing performance indicators has to understand is that if they are going to influence performance in the hospital quoted by my hon. Friend Mrs. Browning, for example, the indicators against which the institution is to be judged must have a broad measure of support within the institution itself, and within the wider health community. That does not mean that every single person working in the health service has to accept every single indicator, but it certainly means that we cannot be content with a position in which only 15 per cent. of primary care trusts believe that the star indicators published last year were fair. If only 15 per cent. of those people believe that the star system is fair, that is powerful evidence that the Government are failing to deliver their policies in practice.
Why is that the case? There are several reasons, some of which have already been mentioned, some of which have not. One that has already been referred to—and it is hugely important—is the point made by my hon. Friend the Member for Tiverton and Honiton that indicators must reflect the local circumstances of the community that the NHS trust seeks to serve. We have an absurdly over-centralised management system in the health service, when there should be much greater flexibility to allow local PCTs and the local community to set indicators that reflect the particular circumstances of the community that the institution seeks to serve. That is preferable to setting single blanket indicators that apply across the board—the one-size-fits-all approach, which does not work.
The second principle that the Government violate was made crystal clear in the Secretary of State's speech. His central defence to the charge that the South Durham NHS trust indicators had been fixed for political reasons was, "Oh no, they haven't." He reminded the House that the negotiation continued four months after the end of the period ostensibly being measured. He said that the negotiation in July determined the star ratings of NHS trusts during the period ending in the previous March.
It is a pretty basic rule of influencing performance by setting targets or measuring performance through indicators that the targets should be set at the beginning of the period in which one is seeking to influence performance, which allows people to respond to the incentives. If the hospital in the constituency of my hon. Friend the Member for Tiverton and Honiton sets, as it should, key performance indicators at the beginning of the period specifying that trauma patients should be treated within an acceptably short period of time—the maximum in that hospital was probably 48 or 24 hours—there is some chance that the hospital will manage its affairs to meet the target. However, if the key performance indicators are decided four months after the period has ended, it invites all the criticisms to which the Secretary of State has been subjected as a result of the Health Service Journal story about the South Durham trust.
The first principle is that the indicators should be more local and the second is that they should be clear and set before the period that they are designed to influence starts. The third, of course, is that the detail of the targets themselves should be seen to be fair and reasonable, and to reflect a reasonable interpretation of both the efficient use of resources and clinical priorities.
I cite one simple example from my own constituency in Leicestershire—the 12-hour trolley wait target for accident and emergency cases, which is wholly reasonable. I agree with the Government that people should not have to wait on trolleys for more than 12 hours in accident and emergency cases, but it is not surprising that Leicestershire acute hospitals trust finds it bizarre that a maximum of 10 patients in a year are being allowed to escape that target, because it applies as much to the neighbouring trust in Kettering, despite the fact that the Kettering trust treats only 20 per cent. of the the number of patients that are treated in the Leicestershire trust. One is therefore five times more likely to be caught in a 12-hour trolley wait in Kettering, which still achieves its target, than in the bigger trust in Leicestershire. That is an example of a target that is rightly viewed as bizarre in its effect. Targets must be local, clear and accepted as fair by those operating the system.
The Secretary of State is operating a system that does not obey the simple rules of setting targets of accountability in order to affect NHS performance. It is not surprising that he has been subject to the criticism that he is fixing the system to accommodate the South Durham trust. That trust provides a good political anecdote, but it is also an important example because it attracts attention to inadequacies in the accountability mechanism for the health service.
That example also illustrates a broader truth—this is my final point—that Whitehall hates accountability. When Ministers say to civil servants that it would be a good idea to set a series of indicators to judge the performance of a particular aspect of government in a clearly measurable way that is known in advance and makes the Government accountable to the public, the civil servant replies, in that hallowed phrase: "Minister, that is a brave policy, but it puts you at risk of an unhelpful statistic being published in the second week of an election campaign, and what would that do for your career?" What the civil servant really means in providing such paternal care for a Secretary of State's career is that it would not do much for his career as a civil servant if such a statistic were published in the second week of an election campaign.
The whole issue of targets needs to be addressed more seriously in order to ensure that we enforce proper accepted accountability in the health service and for public services more generally. Unless and until we do so, our taxpayers and service users will have to continue to accept second-rate service because none of us will be allowed to know any better.
Turning to the matter in hand, I was disappointed by the major part of the opening speech by Mr. Yeo, who indulged in—to inordinate length—a rather ludicrous conspiracy theory. I am pleased to say that it was effectively refuted by my right hon. Friend the Secretary of State and I do not intend to waste any more time on that matter.
More interesting was the way in which the Opposition Front-Bench spokesman and Mr. Bellingham, who is no longer in his place, let the cat out of the bag regarding their attitude to performance indicators in general. I exempt from that criticism Mr. Dorrell, who made an extremely thoughtful contribution, though I take exception to his mathematical distortion in respect of the differences between the Kettering and Leicestershire trusts. However, I shall take that up with him outside the Chamber, as the matter is rather more complicated than warrants debate here.
However, Conservative Front Bench Members and the hon. Member for North-West Norfolk demonstrated that the Conservatives are not just against, as it says in the Opposition motion, "excessive" reliance on performance indicators, but against all such indicators. That is an extraordinary line for the Conservative party to adopt. The NHS is a public service financed by public money. It is perfectly reasonable for it to be run in line with outcomes that the public require. That is what the performance indicators and, indeed, the NHS framework are designed to do. They are designed to set clear standards and outcomes. The frameworks are partly set by the various royal colleges, but also take into account the views of the public and of sufferers from diseases about how treatment should be shaped. The performance indicators are also clear and are designed to draw attention to the NHS services that the public feel are important. For example, people should not have to wait excessively for in-patient or out-patient services, accident and emergency services and others. It is perfectly reasonable that those performance indicators should be set by the Government, in consultation with the public. I cannot understand why the Conservatives object to that. Do they think that the Government should simply give the NHS and other public services money to spend as they wish, without interference? It is extraordinary that the Conservatives appear to suggest that the public should pay their taxes and buy a pig in a poke when it comes to public services.
Of course it is true that doctors must exercise their clinical judgment about specific treatments for patients. However, when the Conservatives were in charge of the NHS and doctors were allowed to set NHS priorities, a very low priority was often given to operations such as hip replacements—exactly the sort of elective orthopaedic operations to which Mrs. Browning objected. The suspicion was that those operations were given a low priority because they are not very interesting to do. They are dead straightforward; one needs to be reasonably competent, but for surgeons it is much more interesting to concentrate on the big, challenging operations.
However, every hon. Member knows that hip replacements are incredibly important to constituents. The problems that such operations resolve are not life threatening, although old people who have to wait for treatment are much more prone to die from other conditions. Delays in hip replacement operations can have an extremely detrimental effect on people's quality of life. That is one reason why it is very important to have performance indicators that reduce the waiting time for such operations.
I return now to the point made by the hon. Member for Tiverton and Honiton. Did she raise the matter with the Member of Parliament representing the constituency in which the hospital is sited? The issues that she raised have a much wider importance than their effect on her relative, and I repeat that the question is one of resources and their proper management. The hospital in my area faces similar problems, and it has brought in French surgeons to work in operating theatres at weekends to clear some of the backlog. Our own surgeons were working so many hours that they could not be asked to do any more. I do not understand why the hospital to which the hon. Lady referred did not do the same, instead of blaming performance indicators.
I want to clarify the record. I am more concerned about the waiting lists for trauma surgery than the waiting lists for elective hip surgery. My point was that if there are 30 people suffering from traumatic injuries, one of them might have a fractured neck of femur. That person might be required to wait five days for an operation, on a regimen of nil by mouth. It is wrong to put elective surgery ahead of that operation in order to meet a target. Finally, I assure the hon. Lady that I have raised the matter with the relevant Member of Parliament.
I think that the question is one of resources. The hospital concerned should have managed its resources better. It is not a matter of targets distorting provision, as it is also important to meet elective surgery targets.
I find the general attack made on performance indicators by some Conservative Front-Bench Members extraordinary, especially given that they belong to the Conservative party. They would not expect businesses to operate without performance indicators, so I do not understand why they think that public services should do so. Moreover, those indicators are set in ways that the public clearly support.
Do the Opposition object to specific targets? My hon. Friend Mr. McCabe, who has just left the Chamber, talked about some of the specific targets. It would be helpful if Opposition Members would say which targets they object to. Do they object to targets on waiting times, or on cancer death rates? Which targets would they get rid of, or do they want to get rid of them all?
I turn now to my constituency, which has had a rather interesting experience with the star rating system. This year, the hospital and the PCT that serve my constituency, and the constituency of my hon. Friend Brian White, were zero rated. That zero rating was quite properly applied, as the hospital and the PCT failed to meet their budgets and to meet their waiting times and accident and emergency targets.
They failed to meet those targets because of under capacity in the Milton Keynes general hospital, which is a direct inheritance of the years when the previous Conservative Government were in charge of the NHS. Milton Keynes is a growth area: its population has grown by between 2 per cent. and 3 per cent. a year since goodness knows when. However, in the 10 years preceding the election of the present Government, not one extra bed was provided at Milton Keynes general hospital. Clearly, the hospital suffered from under capacity in that time, and it has not caught up yet. This Government have been very generous in the funding that they have made available and the problem is not as bad as it used to be, but the hospital still suffers from under capacity. That is why it and the PCT were zero rated.
That zero rating highlighted even more clearly a problem that I and my hon. Friend the Member for Milton Keynes, North-East had highlighted already in our frequent representations to Ministers. The Modernisation Agency has studied the general hospital and the PCT and has crawled all over everything that is being done. It has come to the view that there is very little more that the management could do to improve matters. It has confirmed that the problem is the result of under capacity and not poor management. As a result, the case that I and my hon. Friend have been making has been strengthened. We have presented it again to my right hon. Friend the Secretary of State, who was kind enough to meet us just before Christmas. We are both confident that my right hon. Friend will devote even more resources to the problem.
The experience in Milton Keynes is therefore that the star rating system helps to make clear where a hospital or PCT is encountering problems. It is then possible for the PCT and the Department of Health to look into why those problems have arisen, and to address them.
The hon. Lady says that the hospital in her constituency has a zero star rating. Does she accept that people consider that to be an expression by the Government of the quality of practice in the hospital? The hospital may have very good clinical practice, and she has said that the zero star rating is the result of under capacity. However, the star rating does not indicate whether the hospital is meeting its targets in terms of capacity; it is interpreted by people as a much wider expression of patient satisfaction. Patient satisfaction may be high if there is good clinical practice.
In Milton Keynes, hospital managers and workers, and members of the public, are well aware of what the problem is. I and my hon. Friend the Member for Milton Keynes, North-East have been in dialogue with the hospital management. We have made it very clear that we understand that the problems that have been encountered are not the result of poor performance by anybody working in the health service in Milton Keynes, but that they are the result of under capacity. We have also made that clear to the Government.
Although everybody was very disappointed that the rating slipped from one star back to a zero star rating, we all knew that the problem was one of under capacity—and that my right hon. Friend the Secretary of State was aware of that too. People were confident that the problem would be tackled, because it was evident that only by dealing with under capacity would the hospital's performance be improved.
I should add that matters have already improved in Milton Keynes. Since the star ratings were handed out, our clinical precision unit has opened. It has greatly relieved pressure on the A and E unit, and a story in my local press this week suggests that performance is now worth something like two stars rather than zero.
Finally, I believe that the Government's commitment to a properly funded NHS is self-evident. However, greater public funding must always be coupled with clear direction through the use of performance indicators and the national service framework. In that way, the money that comes from people's taxes can be spent on improving outputs. That must also be coupled with a continued drive to modernise the way in which health services are delivered across the piece.
I am surprised that the Conservatives appear not to go along with the approach of increased funding, modernisation and a sensible system of performance indicators. I agree with my colleagues that the Conservative Front-Bench spokesmen seek simply to denigrate the NHS to soften people up in order to return to the two-tier system that the previous Government were trying to introduce.
I want to build on the excellent speech made by my right hon. Friend Mr. Dorrell. Those of us who want the NHS to succeed know that that success depends not on the number of targets that we can generate, or even what they are, but on the management calibre that we bring to it, the teamwork and involvement of clinicians in a common vision of what they can achieve, and a framework of motivation and discretion within which they may operate. That of course is where the whole question of the target-based framework starts to apply.
Like other hon. Members, I do not believe that it is at all surprising that we have seen a proliferation in the number of targets. In fact, given that the Government have committed themselves to investing hugely greater resources in a substantially unreformed system with, in many cases, quite weak management, it is perfectly reasonable of them to say that they want to measure the outcomes. We must remember that in the early years, from 1999 to 2001, we had a 21 per cent. increase in expenditure for an increase in outputs of approximately 1.6 per cent. There are different ways of measuring output, but it is predictable that any Government faced with that sort of problem will want to establish greater clarity and measurement of performance.
It is equally true, as Labour Members have said, that if we are ever to create any sort of internal market or sense of choice in the health service, the public need transparency of performance so that they may exercise whatever choices might be available in future. I am not, therefore, against the idea of targets or measures for their own sake. The issue is what part they should play in management and how they help build better-quality management with better clinical involvement as well as the right framework of motivation and commitment.
The starting point is the sheer proliferation in the number of targets. It is quite unreasonable to generate so many targets that it is impossible for management to devote a reasonable amount of time to any single one of them. Chief executives of NHS trusts have 420 different targets to pursue. According to responses to my parliamentary questions, there are 151 performance indicators, up from 86 last year. That proliferation is a reflection of the preoccupation of Ministers and the Government with trying to impose control. Every time a new issue arises and every time something remotely threatening or critical of Government crosses their radar screen, it is extremely tempting to impose another target.
The delusion is that a target will in any sense be a substitute for effective management.The target system is at risk of becoming a substitute for management. It is inevitable that it will be politicised; that is the nature of our system, and the episode with the South Durham Health Care NHS trust illustrates how a target-based system leaves Governments vulnerable to that. For management, that results in a vicious circle of demoralisation, a wedge between clinicians and management and a resulting decline in the calibre of people and resources available and rising costs in NHS administration.
The hon. Gentleman has made it clear that he is not against all targets, but against the extent of the targets. Will he make it clear which particular targets he is against? Which does he believe to be irrelevant, and which should be discounted?
The hon. Gentleman asks a perfectly reasonable question. It is obvious that removing any of the existing targets would be a difficult and sensitive problem. I put it to him, however, that if targets are to achieve any reasonable purpose, there is no point in having more of them than the chief executives and management of trusts can sensibly devote their time to. All that does is invite them to fail. It is inevitable that some trusts, even excellent ones, will underperform on some of the 420 different targets. As a result, the idea will be encouraged among the general public that the NHS is failing. I put it to Ministers that if they are sincere in their commitment to restoring public confidence in the NHS, and if they want to demonstrate that there is improvement, the first thing to address is the nature of the targets and whether they are giving the NHS a feasible or deliverable set of outcomes.
No one should be deluded about the extent of the problem. By way of illustration, the British Medial Journal survey of clinical directors on
The evidence from all over the world of what succeeds in health management shows that it is top-calibre people and a common clinical vision. World-leading organisations, such as Kaiser Permanente in the United States, specialise in that. We need not more managers, but fewer. The Solucient study of the top 100 US hospitals found that they had 25 per cent. fewer managers and administrators than the average hospital.
Yet the target-based culture will inevitably create more administration and management for no clinical purpose. The reality is that as long as we create huge numbers of targets, changing them every year, we will create a highly politicised system. While the Secretary of State acts, in effect, as the executive chairman of the NHS and is held accountable from day to day for the targets set, it is in the DNA of the system that we have that it is highly politicised, unless those targets are separated from the process of Government and there is a process of audit and verification that is seen to be independent.
The hon. Gentleman is making an extremely interesting and constructive speech. I do not recognise the 400-odd targets to which he has referred; I estimate that there are about 62. It is arguable whether there are too many; that is a moot point. Certainly, however, we will have that many in future precisely for the reasons that the hon. Gentleman has given about the need for strong leadership and so on in the first instance, which perhaps is not there. A radical transformation requires a degree of—I will not call it autocracy—central direction of targets, which will increasingly disperse downwards as we go through the transformation. I agree with a great deal of what the hon. Gentleman says, though I do not necessarily agree with his numbers.
I thank the Secretary of State for that. I do not want to engage now in a debate about the numbers, but would say only that they are quoted from responses to parliamentary questions that I have asked of his ministerial colleagues. We can engage in discussion about the figures at a later date.
What I do put to the Secretary of State, and what I think is undeniable, is that there is a question of morale among the management of NHS trusts. The evidence for that is widespread, not least in the recent MORI survey showing that 62 per cent. of chief executives said, when asked about the target culture, that their role was becoming increasingly unattractive. Some 66 per cent. said that the NHS was losing its best leaders, and 69 per cent. said that negative perceptions now make it hard to attract clinicians into management, something which it is extremely important to achieve. The result is undoubtedly the loss of good managers and a failure to attract new management talent into the NHS, which is an increasingly difficult task when salaries are comparatively less competitive and perceptions are comparatively negative. Creating a management framework that is motivational for people, within which chief executives believe that they have the wherewithal to deliver their outcomes—a feasible set of outcomes—is absolutely crucial to the future stewardship of the health service and individual hospitals. Our system is simply not achieving that, and the target culture is one reason why.
On top of that, I believe that the average life of a chief executive of an NHS trust is only 700 days in the job. One reason for that is that there have been substantial changes in management and mergers in the NHS, but it also results from the demoralisation and despair many managers feel about their ability to deliver in their role. At the same time, there has been a huge proliferation in the number of administrators. Ministers have failed to explain why the number of NHS administrators has increased. There may be many different reasons for that. One is that many of them are engaged in monitoring and responding to the scatter-gun approach to the proliferation of targets. I understand that the number of administrators may begin to reduce, but we have yet to see that. There was a huge increase—48 per cent.—between 1995 and 2001 compared with a 7.8 per cent. increase in the number of nursing and clinical staff.
Faced with a crisis of management in the health service, according to my parliamentary questions—the Minister of State, Mr. Hutton and I have had a dialogue on this—the Department has no knowledge of the career background of 60 per cent. of NHS chief executives. He has told me that that is not right, but it is the response that I received to my parliamentary questions. Even if the responses are incorrect, which I am prepared to accept, they must reflect the management priorities and the attitudes of Ministers.
Just in case anyone thinks that targets do not affect attitudes within the NHS and among managers, I refer hon. Members to the article in the British Medical Journal on
"How to make a silk purse from a sow's ear—a comprehensive review of strategies to optimise data for corrupt managers and incompetent clinicians".
Some of it is gripping, some is tongue in cheek, but it does say:
"Surgeons' and hospitals' positions in league tables can make or break their reputations. They therefore need to learn how to present data in the best possible light."
It refers to different ways of distorting the data and how managers and clinicians can represent themselves in the best possible light. It concludes by saying:
"Performance managed healthcare settings encourage gaming and "creative accounting" of data. Creative accounting is driven by three dominant factor—attracting additional resources, meeting performance related targets, and improving positions in league tables".
That is what administrators talk about. If Ministers can show that the target system is not distorting management priorities, they have to explain why everything in that article is wrong.
Unless we get a different approach to management—one that concentrates more on developing quality leaders in the NHS; on getting better co-ordination between those leaders, managers and clinicians; on developing a common clinical vision of what is to be achieved; and on moving away from what is seen as a highly mechanical and one-size-fits-all approach to target setting—we will not get good value for money from the extra investment.
Comment has been made on an ex-Secretary of State for Health. I begin by commenting on an ex-shadow Secretary of State for Health. Dr. Fox may be gone, but it will be some time before Labour Members forget his disarming honesty about Tory health tactics. Fox by name, but certainly not by nature. There was nothing cunning or shrewd about his crude campaign to disparage the efforts of NHS staff and undermine the principle of a publicly funded collective health system.
As the Daily Mirror revealed, the hon. Gentleman's tenure was dedicated to creating a four-point plan with the clear aim of fuelling public cynicism about the NHS. He fed the belief that the NHS is a financial black hole and that the people who work in it are incapable of improving it and of spending the public's money properly. Accordingly, the architect of that nasty plan has been rewarded with the chairmanship of the nasty party. What is revealing about the debate is that we now know for sure that the so-called new team on the Conservative Front Bench is sticking with that unsavoury doctrine. Part of it means undermining confidence in any mechanism that shows whether the NHS is improving. That is the essential context for the debate on the star rating system.
At other times, the attack takes a different tack, but the fundamental point is the same. Conservatives complain of the productivity gap—that double-figure percentage increases in funding lead to single-figure increases in productivity. It is an argument that shamelessly skates over the fact that the outgoing Conservative Administration left the NHS bereft of the human and physical capital it needed, something to which my hon. Friend Dr. Starkey alluded. Given the time it takes to train clinical staff and build high-tech health facilities, there will inevitably be a lag before productivity levels rise again.
What even the Conservatives cannot talk down are the black-and-white facts in the NHS chief executive's report published only in December. It shows solid progress and improvement that is a tribute to all concerned—Ministers, managers, nurses and doctors. It is hardly surprising if the public are unaware of the report's contents because it was largely dismissed by the media, presumably because the message was not what they wanted to hear. It reported substantial and sustained reductions in waiting times and waiting lists, a major increase in productivity and, interestingly, that the public now rely heavily on services dismissed as a gimmick by both main Opposition parties. In 2002–03, NHS Direct handled 6,319,000 calls and there were 1,373,000 visits to NHS walk-in centres. Now the Conservatives criticise the NHS star rating system in the same way. That is part of the Fox plan and it should be dismissed.
Patients in our borough are served by the Wrightington, Wigan and Leigh NHS trust. Initially, it was awarded a two-star rating, but after a couple of years of steady improvement and management focus on the weaknesses identified by the performance indicators, last year it received a three-star rating. The achievement of three stars has boosted morale and staff were rightly rewarded with an extra day off. Morale has clearly improved—[Interruption.] Mr. Dorrell laughs. He was a Minister in that Conservative Government. What a difference it must be for members of staff to work in a health service that is on the up and receiving investment. They can feel improvements in the air, unlike when they worked in the health service in 1996, when it was under his stewardship and cuts and decline were the order of the day. It must be a very different place to work. My thanks go to the staff of the Wrightington, Wigan and Leigh NHS trust, and in particular to Sheena Cumiskey, the chief executive, and Brian Strett, the chair.
The trust is moving forward, with an application for foundation status having achieved three stars. That application is supported by the staff at our trust. Perhaps some of my hon. Friends have not given enough thought to that. It gives Leigh, the other town in the borough, a chance to shape the future of our own hospital, Leigh infirmary. I will call on local people to seize that opportunity to give our hospital a new future, given the powers that foundation status will, I hope, give us.
It is not just our trust that has had a positive experience of the star rating system. There is substantial evidence that it has lifted performance across the NHS. Let us consider the evidence given to the Health Committee's inquiry on foundation trusts—of which Mr. Burns is a member. Mr. David Jackson, chief executive of the Bradford Hospitals NHS trust, said:
"I can tell you that when we became a three-star trust—and I was very cynical about the whole process—the atmosphere in the hospital changed and people felt they had been recognised for the hard work and motivation and commitment and it had a very tangible beneficial effect."
Mr. Nik Patten, deputy chief executive of the South Tees Hospitals NHS trust told us:
"We missed three stars very marginally last year; our inpatient data was very, very good but our forms in two areas were slightly off the leading pace . . . We were disappointed that we did not get three stars . . . Having failed last year marginally, we want to achieve that three-star status."
He agreed that it had energised the trust rather than demoralised it.
The improvement that the chief executive report catalogues is a huge tribute to the work of my right hon. Friend Mr. Milburn. His real achievement for patients and people in this country stands in stark contrast to the pettiness of the Opposition motion. That said, I want the Government to make more progress on one thing. Now that the NHS is back on its feet, I want our focus to switch to a sustained attack on entrenched ill health in some of our most deprived communities and to the health inequalities that still blight Britain. We have only scratched the surface. We need to tackle those huge structural and cultural problems. Ironically, that is a call for more political influence on the allocation of NHS resources.
Last year Members, including me, lobbied hard for a change in the resource allocation formula that had previously been driven predominantly by factors such as old age. We succeeded. The Secretary of State listened and produced a formula that gives far more weight to deprivation and ill health as the guiding principles of resource allocation. However, in practice, we have yet to see the major shift in resources that the change in the formula accepts is necessary.
Recently, I tabled a parliamentary question to the Department of Health to ask how far each primary care trust was from its target funding in the third year of the current spending review. The results are revealing. In some of the most affluent parts of the country, PCTs will be significantly over the target. Westminster will be £76 million over target. The figure will be £41 million in Wandsworth; £27 million in East Elmbridge and Mid Surrey; £18 million in Guildford and £19 million in Cambridge. However, in some of the most deprived parts of the country, with the most entrenched problems of ill health, the picture is reversed and PCTs are hugely under target. That is because although the formula now recognises the health needs of those communities, they do not yet have the resources. Central Liverpool is £26 million under target. The figure is £25 million for the Heart of Birmingham PCT; £24 million for Barking and Dagenham; £25 million for Easington; and in Ashton, Leigh and Wigan—my PCT—it is £12 million.
I understand the rationale for the Department of Health's pace of change policy and the destabilising effects that could result from a rapid reallocation of NHS resources, but at a time of rising NHS funding the pace of change is far too slow. It is time to target new funding on the areas of the country where health is worst and that the Department itself accepts need significantly more resources.
That focus should guide the Department's work in the medium term and it should be the bold agenda that guides a third-term Labour Government.
I begin by agreeing with Mr. Dorrell and other speakers: I do not want the abolition of star ratings because they have an important part to play. However, I want to discuss their accuracy and appropriateness and some of their unwanted effects, and especially to press for more notice to be taken of the views of patients when NHS ratings are being drawn up. I hope that the presence of the Commission for Patient and Public Involvement in Health will help to ensure that the new Commission for Healthcare Audit and Inspection actually takes much more account of the views of patients.
The assessment of quality in the NHS is a great interest of mine. Indeed, I held an extremely intimate Adjournment debate on the subject in Westminster Hall with a Health Minister on
I argued that the people of whom it is most important to take account when establishing star ratings were being neglected. They are, of course, the recipients of health care—the patients—and its providers, the nurses and doctors. I shall not repeat what I said at that debate, but my views on the accuracy of the star ratings were borne out by the Audit Commission's report, "Achieving the NHS Plan", which concluded that the number of stars related only weakly to performance and management adequacy. The commission gave the stark illustration of a trust awarded two stars, yet from the detailed knowledge of the commission's local auditors it described that trust as "failing".
I want to discuss the appropriateness of the current performance indicators and some of the possible unwanted effects of the system. As other hon. Members have pointed out, the indicators are incredibly important; the ratings carry rewards and foundation trust status. As an aside, it is no wonder that staff who are about to receive foundation status welcome it—it brings rewards. However, that high importance can bring risks. The Royal College of Nursing, in its submission to the Public Administration Committee's inquiry into targets, pointed out that there is a risk of influencing staff behaviour away from the best interests of patient care. A further risk is that to meet the target for seeing out-patients some trusts see more new patients at the cost of making essential follow-ups.
Trusts may look for ways around the targets. Examples from accident and emergency departments have received much publicity: trolleys are converted to beds, waiting areas in other departments are used for patients, and there are queues of ambulances outside. Such cases have been well rehearsed in the past.
The wait for out-patients begins only when the general practitioner's referral letter is logged in. That logging in may be delayed or, even worse, the letters may be lost. I have just received a letter from a constituent whose first delay occurred because the appointment letter was lost. A subsequent letter, in which he expected to be given a date for his appointment, stated:
"Now you are on the outpatient waiting list to see Dr. X . . . the current waiting time is approximately 18 weeks . . . We will contact you about 4 weeks before the anticipated appointment time."
It appears that there is a waiting list for the waiting list. Does the Minister admit that that is happening and is the practice widespread?
Another risk is the cancellation of admissions for elective surgery for non-clinical reasons. What are the rules about that? Cancellation on the day of the operation is obviously counted, but can the trust avoid the stigma of cancellation by not recording it if it occurs earlier than that?
An example of the inappropriateness of one existing target was published last August in the Journal of the Royal Society of Medicine. Urologists at Medway Maritime hospital considered the effects of the two-week rule for seeing patients with suspected urological cancers. They found that although it achieved more rapid times for seeing patients it had no effect at all on the interval between referral and receiving definitive treatment. There were delays for scans, X-rays, and operating theatre time. I understand that the Government have spotted that problem and that by the end of 2005 the target for all cancer treatment will be two months from urgent referral to actual treatment. Sadly, that is a long way away for patients today and I wish it could be sooner, although obviously it is an improvement.
My quandary today is which way to vote. There are valid points in the Opposition motion, but there are also valid points in the Government amendment. I shall almost certainly take the step that only I am allowed to take and vote for both the amendment and the motion. I cannot see that there is anything mutually exclusive in either. I hope that when the Minister responds to the debate he will not attack the Conservative Opposition politically, as has occurred so often in the past during questions and debates—even Mr. Speaker has referred to the matter—by hiding behind their refusal to vote for more money for the NHS, rather than actually answering the questions.
As I have said, I am not arguing for the abandonment of star ratings—I am merely arguing for greater reliability, greater local relevance, a greater impact of staff and patients' views and, above all, a greater emphasis on outcomes.
"Whether spending more or doing more improves population health is sometimes asserted, but never measured systematically and demonstrated. Ignorance is bliss, no doubt, for decision-makers in Whitehall."
I shall be reasonably brief, as others wish to speak.
I am very pleased that we are having this debate, because Members on both sides of the House are finding it useful. I am also pleased that the Secretary of State was able to explain how the star ratings are evolving, and how the indicators are changing year on year. It was reassuring to hear about the transparency of the system, and to learn that patients' involvement and experience were at the forefront, so that the patients could see that they were playing a part in the performance of hospitals.
The facts are stark. The Government are putting record amounts of money into the health service: no one could deny that. It is important, however, to ensure that the investment is not wasted but is used to make genuine improvements in patient care. There is the rub: it is impossible to know how well investment is doing unless there is a coherent way of measuring outcomes.
I do not want to dwell on this for too long, because many Members on both sides of the House have rehearsed the same arguments, but we obviously need a robust and coherent system of measurement to ensure that we are using money wisely—that it is targeted where it is needed most, and that we see genuine improvements in outcomes.
Mrs. Browning told a harrowing story of a patient who had suffered trauma. That is clearly unacceptable. Anyone experiencing such trauma will have a significant chance of experiencing long-term ill health and possibly early death if it is not treated quickly. I would certainly consider it unacceptable if people waited for five days for a similar operation at my local hospital. Without transparency, though, we do not know what is going on in our hospitals.
My local trust, the Dartford and Gravesham NHS trust, opened one of the first new hospitals under the private finance initiative following this Government's election. The fantastic new building won various design awards. Size was always going to be a problem—the hospital was never going to be large enough for an expanding population in a part of north-west Kent that is experiencing huge growth—and it soon became clear that the Government's expectations were not being met. I received complaint after complaint. Operations were being cancelled, and people were waiting on trolleys in accident and emergency for unacceptable periods.
Many factors were blamed for the problems in the early days. Some people said that there was too much management; others claimed that it was the wrong sort of management, or that the number of beds was wrong. The hospital received a zero star rating. Then, however, there was a change of culture: we appointed a new manager, Sue Jennings, who brought in a new management team. Something very radical then happened. There were no additional beds, and there was no reduction in the number of managers, but within a year of Sue Jennings's arrival the hospital had one star and the following year it had three.
The effect on morale has been dramatic. When I walk into the hospital I see that everyone is smiling. Patients are smiling, staff are smiling, and the porters welcome those who enter with a spring in their step. That change in the culture is itself driving improvements and innovations, and genuinely improving patients' experience. It is almost impossible to describe the enormous improvements that have been made. I am not saying that everything is perfect, but that change in the culture has taken place—not because of huge expansion or a radical change in the number of managers, but simply because beds are being managed more effectively by more efficient managers.
The only way in which we can objectively tell that such things are happening is through performance indicators such as the star rating system. The proof of the pudding is in the eating. The number of complaints I receive has fallen to almost zero, and the number of letters I receive from constituents saying, "I had a really good experience in the hospital," has increased dramatically. That is not accidental; it is due to the enormous amount of work put in by all the trust's staff. The whole situation has been radically improved by the fact that performance indicators enable staff and others to see how much the trust has improved, and how the culture of the hospital has changed.
I would counsel strongly against the assumption that a sudden increase in the number of beds, or a sudden change in the number of managers, can make a massive difference. It cannot; we are talking about a change in culture, and the ability to demonstrate how much a hospital has improved.
Let me give a classic example. When the hospital first opened and was clearly not doing particularly well, people would come to my surgery and say, "The Government are failing: the hospital is no good." I would say, "Look at the extra money that is going in." They would respond, "The extra money is making no difference. I am still having to wait for 12 hours on a trolley, or to wait for three months for an out-patient appointment. My operation has been cancelled. Your money is not doing any good." It was very difficult to persuade people that Government investment was making a difference. Now I can say, "Look at the performance indicators. Look at how the hospital has come on in the last couple of years"—and they now say, "Yes, I see that the money is beginning to make a difference. It is beginning to produce the improvements we have been demanding for the last few years."
Debates like this are important because they give us an opportunity to air differences of opinion and to share our experiences. It is also important that our constituents can see what is going on in their hospitals, and ensure that what we hope to achieve is being achieved.
The message is clear: the Government must go on investing in the health service as it is now. We shall not see an end to five-day waits for trauma surgery unless hospitals receive more investment, but it is clear that if hospitals do not use money effectively and have no effective measures to compare their performance with performances elsewhere in the region and the country as a whole, and with national standards, we shall not see the best results. There is no point in every hospital's reinventing the wheel. What is most important is for hospitals to take best practice from parts of the country where the system is clearly working, and use it to model their own performance. They will not necessarily perform in exactly the same way, because different local circumstances will require different approaches. But the only way in which to ensure that best practice is adopted throughout the country is to provide robust performance indicators that can be reproduced, so that we can genuinely compare like with like on a national basis.
I am very pleased that my hospital has improved so much, and I am sure that other Members can recount similar stories. As long as the Government's money is invested and as long as it is spent wisely, everyone—particularly patients and NHS staff—will reap the rewards.
It is a great privilege to follow the very constructive contribution from Dr. Stoate, which had more in common with the contributions from my hon. Friends the Members for Tiverton and Honiton (Mrs. Browning) and for Tunbridge Wells (Mr. Norman) and my right hon. Friend Mr. Dorrell than with that made from his own Front Bench.
The key question underlying the debate on the health service today is why, despite the superb dedication of NHS staff, the huge increase in taxpayers' money going into the health service has not resulted in a commensurate increase and improvement in clinical services. In a nutshell, the reason is that those resources are allocated by a system that is highly centralised and micro-managed from the centre and where the management is driven by the desire for media manipulation and good headlines in the press tomorrow. Perhaps I can give some concrete examples of how that obsession with media manipulation and micro-management at the centre results in, at best, waste and, at worst, the undermining of clinical standards and, invariably, staff morale.
The Government announced a waiting list initiative. They got a good headline. They announced a waiting list budget for each hospital—another good headline. They announced that each hospital should have a waiting list manager—a third good headline. What does that mean in practice? Well, in hospital A—I am not at liberty to reveal which hospital that is, but it is not in my constituency—the waiting list manager used his waiting list budget to meet his waiting list target by employing locum surgeons on Sundays, at much extra expense, but from his extra budget, to operate on people on the waiting list. That seems a good idea—expensive, but on first sight, it would reduce the waiting lists. Unfortunately, sterilisation teams are not employed on those Sundays, so all the equipment needs sterilising by the end of Sunday. Come Monday, no operation can be performed until late in the day, when all the equipment has been sterilised, but that is part of a different budget, so it does not matter. So a huge amount of money has been wasted for no extra improvement or no reduction in the waiting list. That is waste, but the result can be much worse than waste.
In the same hospital, one of the senior consultants had made major advances in reducing infection—I shall refer to that problem again in a minute—by having a dedicated ward where people went after open-wound surgery. No one with an infection was allowed on the ward. But the waiting list manager, up against his waiting list target, had some people on the list who would go over the target by just a few extra days, so the senior consultant found that they were plonked on his ward. Some of them had bowel infections—one even has MRSA—so he said that he was not prepared to operate with those infections in the feeder ward for his operating theatre. He was told that he had to, because he had to meet his targets. He said, "Well, I will if you insist." He told his patients that they could be operated on if they would first sign a disclaimer, which they would be wise to do only if they were feeling suicidal, so no operations were carried out that day. More waste, and possibly a risk to people's lives as a result of a target-driven culture in the health service. So that is what the Government's policies mean in concrete terms, and those are not isolated examples.
Patients are not interested in targets; they want to know that, when they go for treatment in hospital, they will come out healthier than when they came in. Sadly, we have a system where nearly one in 10 patients who go into hospital acquire an infection that they did not have before they went in. According to the National Audit Office, between 5,000 and 20,000 people die of superbug infections that they get in hospitals. The European Union says that the situation is worse in our hospitals than in any other country in Europe and getting worse faster in this country than elsewhere in Europe.
When that first became a matter for public concern, the Government's response was to set up a system of traffic light indicators for hospital cleanliness: red for not so clean, amber for okay and green for fine. Unfortunately, they then discovered that, of the 20 hospitals with the highest level of MRSA superbug infection in the country, they had rated 15 green, five amber and none red. So they have naturally kept quiet about that expensive, time-consuming, costly and bureaucratic initiative for some while.
I managed to raise the issue with the Prime Minister recently, asking him why we were fighting and losing that biological war in our hospitals. He said that I should not discuss negative aspects of NHS hospitals, but all hon. Members have to raise those matters and should continue to do so until our record is not the worst but the best in Europe. I will do so particularly because I had a hospital with one of the highest levels of MRSA infection serving my constituents. I am glad to say—I pay tribute to it—that it has halved that level during the past year, which shows that it can be done and that improvements can be made.
A few days after I raised the issue with the Prime Minister, the Secretary of State—I regret that he is not here—announced with great fanfare a new initiative to deal with superbugs. There were headlines in all the newspapers. I asked whether he would make a statement about that new initiative and those new policies in Parliament. He wrote back to me, saying:
"For the record, the press notice last Friday did not announce any new policy."
The press statement actually says:
"Mr. Reid gave his backing to wide-ranging proposals . . . which seek to revolutionise the way potential infections are handled in hospitals" involving,
"new rules . . . a new system . . . a new drive . . . new plans".
Apparently not new policies, however. It may well be that the Minister is happy to deceive the newspapers. I am certainly not accusing him of deceiving the House—I am accusing him of telling the truth to the House by saying that he does not have new policies to deal with an issue on which he should have new policies.
In following this situation, I have done more than 20 radio and media interviews with consultants and people from the Academy for Infection Management. They have proposals to deal better with the problem, so why are the Government not giving them serious consideration? I have received many e-mails from consultants and doctors throughout the country pointing out what is happening and saying that solving the problem does not require large expenditure. The solution requires, above all, a transfer of responsibility back from management and bureaucracy to local clinical people. If that were successfully adhered to, it would save massive amounts, but it is not allowed because of the target-driven culture.
One e-mail I received said:
"We have managed to keep MRSA out of our rehabilitation unit by a combination of pre-screening, rigorous hygiene and vigorous treatment . . . However, we have been put under pressure to relax our criteria because they delay transfers".
It says that there is a target
"to move people out of casualty departments within a set time", so targets are putting pressure on the person who wrote the e-mail to undermine the clinical standards that were saving lives. The issue is important and I am sorry that the Secretary of State is not in the Chamber to tell us why he has no policies to deal with something that is killing thousands of our constituents. I hope that the Minister of State, Mr. Hutton, who will wind up the debate, will tackle the problem more seriously than his colleagues have so far.
In the few moments available to me I shall single out one or two of the points that I wish to make. I had a sense of déjà vu when I read the motion, because the substantive issues have been debated fairly comprehensively before. I took part in a debate on performance indicators and targets in October last year and, of course, the South Durham health care trust has been the subject of several questions in the Chamber, which have been adequately dealt with on each occasion. I can only deduce that the official Opposition's tactic is to reiterate a specific line of attack in the hope that constant denigration of, and carping about, performance indicators, targets and star ratings will somehow mask the huge improvements in the output of the NHS that are a result of Labour's investment in it.
Conservative Members do not want to talk about the real issues that affect people's everyday lives, such as the length of time that they wait before they see their general practitioner or go into hospital for an operation, the number of people on waiting lists or the time that they have to spend in accident and emergency departments. Conservative Members do not want to discuss those points because they know that all the evidence from the indicators shows that the investment that Labour puts into the NHS is paying dividends and that the public appreciate that. They know that the NHS is the most popular service in the country—a service that not only improves the quality of life of millions of people but increases the length of their lives.
A publicly funded service that is free at the point of delivery encapsulates Labour's values through and through. Conservative Members realise that if people appreciate that the principles that underpin the NHS pay dividends, they will support Labour at the next general election. They will therefore do everything in their political power to denigrate the service and hide the reality of the situation. In short, the motion is a politically motivated attack that is not rooted in the reality of people's everyday experience of the NHS, but designed to mask that reality in the interests of short-term political dividends for the Conservative party.
In some respects, this has been an enlightening debate, but not in others. Conservative Members have shed considerable light on performance indicators, the way in which performance should be measured, the excessive nature of performance indicators and Government requirements for information, and the distortion of clinical priorities in the NHS and the severe consequences of the transfer of performance measurement to a system of centrally determined targets. My hon. Friends made excellent contributions, which reflected their experience in senior positions, both in government and in the private sector, and thus had a strong bearing on the way in which performance management should be conducted in large organisations. Their contributions also reflected their personal experience and the experience of real people.
Mr. Burstow took up some of the forceful points made by my hon. Friend Mr. Yeo in his opening speech, but also raised the issue of Basildon and Thurrock. Can the Minister explain why, if the failure of the star ratings for Basildon and Thurrock was connected to patient surveys and patients' experience, the exclusion of catering, information technology and management criteria led to an increase in those ratings? The hon. Member for Sutton and Cheam referred to the excessive requests for information from the Government. The NHS Confederation produced a report just last month based on the experience of Manchester hospitals in which it said that there had been
"a considerable increase in often unco-ordinated ad hoc requests . . . The quality of data provided at very short notice will be poor . . . Demands from the centre have often been poorly defined and do not always ask the right question . . . Information is requested without checking whether it already exists, leading to duplication."
The confederation also says that
"there is a lack of feedback on how information is used."
As has been said, those hospitals concluded that more than half of the information requests that they received were not perceived to be useful for the management of the trust.
That brings me to a point made by my right hon. Friend Mr. Dorrell. If a system of performance management, information gathering and data collection is to be devised within a large organisation, it should meet the trust's priorities. If we are serious about the devolution of management in the NHS—and Conservative Members are—priorities should be determined locally, so the system of performance of management should be devised locally and not centrally imposed. My hon. Friend Mrs. Browning spoke about the experience of real people in the NHS, which, as Dr. Stoate rightly said, we should take to heart and acknowledge. I am sorry that my hon. Friend's speech was followed by that of Mr. McCabe, which did not reflect the experience of real people in the NHS. I do not think that Dr. Starkey is aware of what is happening in the NHS. She said that everyone in her hospital in Milton Keynes agreed that there was a problem but she went on to say that they needed the star-rating system to tell what it was. There are two three-star hospitals in my constituency—Addenbrooke's, which has been a three-star hospital from the outset, and Papworth, which has been one since 2002. We are a fast-growing area, and have experienced pressures on capacity, but those hospitals have retained their three-star rating. The reasons for that were touched on by the hon. Member for Dartford who, as my right hon. Friend Mr. Lilley said, made a speech in keeping with Conservative philosophy.
It is a matter of culture. It is about delivering in the NHS, which is not happening. Star ratings are not needed in order to deliver. We in South Cambridgeshire knew that Addenbrooke's hospital and Papworth hospital were excellent hospitals before the star rating system. I trust that the Minister of State, Mr. Hutton, visited those hospitals yesterday and discovered that for himself.
If we are to have transparency and accountability in the NHS, as I hope we will, the priorities that are determined locally must be reflected in performance management and in indicators that are accessible to the public. As my hon. Friend Mr. Norman rightly said at the outset of his speech, if we are to implement a system of choice for patients, that requires transparency in performance. Indeed, that is our philosophy. We have got used to Labour Back Benchers and the Government misrepresenting the policies of the Conservative party. Most of the speeches made from the Government Benches suggested that Conservative oppose performance indicators.
We are not opposed to performance indicators. We are opposed to excessive requests for information and excessive reliance on performance indicators. We are opposed to the imposition of performance indicators from the centre, rather than indicators derived from local priorities. We are particularly opposed to a system of targets and star ratings leading to a system of rewards and penalties for those who work in the NHS, which is determined from the centre and which, in the case set out in the motion, could be open to manipulation, as my hon. Friend the Member for South Suffolk said, by those at the centre, particularly Ministers.
That is not a criticism of civil servants; it never was. The Secretary of State rightly defended civil servants. We are defending civil servants by seeking to expose the ministerial interference in the system. Many in the NHS are sceptical of the credibility of the star rating system. That system will be further undermined by the fact that they can now see an instance where it appeared open to ministerial interference.
That brings us back to the case at the heart of the debate. My hon. Friend the Member for South Suffolk asked some questions of the Secretary of State, but he did not get many answers. The Secretary of State did not explain why the Prime Minister has neglected to reply to my hon. Friend's letter. It is all very well replying to my hon. Friend Dr. Fox, but that and the letter from the permanent secretary have served only to raise more questions than they answer.
The Secretary of State relied on a series of changes over the years, but that does not explain why, if the system is changing and has changed last year and this year in the absence of ministerial involvement, ministerial involvement was so necessary in July 2002 to introduce the star rating system. The truth, I suspect, is that Ministers have been taken out of the star rating system in subsequent years, not least because of the interference in July 2002.
Let me ask a question to which the Minister can reply in his winding-up speech. If it was necessary to drop two criteria—access to catering facilities and information management and technology—because the data were poor, were they dropped before
"Unfortunately, even if time allowed it, further revisions to the methodology to promote these trusts"— that is, the so-called high-profile trusts—
"would inevitably lead to other individual results we had not expected, as well as making the scoring system more complicated."
Responding to the request from the Secretary of State, the head of performance development wrote:
"Alterations to the methodology have been made".
The Minister of State said from a sedentary position that there had been no changes to the methodology, but the head of the performance development unit clearly said that there were. He went on to say that those resulted in
"the changes to individual trusts that were requested."
This was not some objective process derived from consultation with trusts and CHAI. It was in response to the Secretary of State's request. The head of the performance development unit went on to say:
"This makes the scoring methodology more difficult to explain and less transparent."
The Government's amendment refers to transparency. We all need transparency in the decision-making process, but it was perfectly clear that, as a result of the former Secretary of State's intervention, the system was made more difficult to explain and less transparent. Why did that happen? We need answers, and the Government have not given them to us.
This has turned out to be something of a surprising debate. It rapidly recovered from the low point that it reached after the contribution of Mr. Yeo and turned into a high-powered, almost policy wonk-style seminar about the virtues and merits of performance assessment, performance indicators and the use of targets. I do not think that that was quite the intention behind the Opposition motion, but the debate was interesting none the less and I should like to return to some of the contributions that have been made.
The other reason why the debate was surprising is that, when I was preparing for it, with some trepidation, I thought that the Opposition would set loose on the Government some of their Back-Bench parliamentary Rottweilers. Instead, to be fair to them, we heard some high-powered contributions from the Opposition Benches, as we did from the Labour Benches. We heard from two former Secretaries of State, a former Minister and a leading member of the former Tory shadow Cabinet. Mr. Dorrell usually speaks a great deal of sense about the national health service, and he did so again today. Many Labour Members would want to agree with much of what he said, but his problem is that no one on the Conservative Front Bench looked too chuffed with what he had to say.
The Tory motion has two components. There is a sort of puerile bit of old crap at the beginning, if I can use that as a parliamentary expression, or a puerile reference to my right hon. Friend Mr. Milburn. It also has a second section dealing with the use of performance indicators. Not a single Conservative Back Bencher referred to the first part of the motion. I know perfectly well why: they recognised that there was not a shred of substance in any of the allegations that the hon. Member for South Suffolk brought before the House today.
I congratulate my hon. Friends the Members for Mitcham and Morden (Siobhain McDonagh) and for Birmingham, Hall Green (Mr. McCabe), who spoke well and certainly rattled Opposition Members, and my hon. Friend Dr. Starkey, who also spoke well. My hon. Friend Andy Burnham made some important points about the funding formula. He will know that my right hon. Friend the Secretary of State is aware of the issues and is considering them very seriously. My hon. Friends the Members for Dartford (Dr. Stoate) and for West Bromwich, West (Mr. Bailey) hit the nail entirely on the head in their analysis of what lay behind the motion.
I want to congratulate Mrs. Browning on her remarks as well. She was right to express her concern about the treatment of one of her relatives, and if she is prepared to write to me about the matter, I shall be very happy to look into it. I interpreted her remarks, perhaps wrongly, as largely an appeal for additional resources for the national health service. With the best will in the world, I do not think that she is in the best position to advance that sort of argument to the House.
Just for the record, I was not asking for more money, but talking about the way in which resources have to be allocated to meet targets instead of trauma cases.
The hon. Lady's comments certainly came across as an appeal for extra resources. I am grateful for her clarification.
Mr. Norman spoke very well and made a number of very important points. He will know that I agree with much of what he has to say about management in the national health service. I look forward to further contributions from him.
Perhaps I should not say this to Dr. Taylor, who flummoxed us all by saying that he was going to vote both for and against the motion, but I do not think that he can do that. If he votes for the amendment, he will be seeking to delete the words of the motion and inserting words proposed by my right hon. Friends. He is welcome to do that, but it will be rather difficult for him to vote against it 10 minutes later.
Mr. Lilley made a very important contribution about hospital-acquired infections. We certainly want to deal with that issue. Of course, it is the responsibility of the chief medical officer, and he is taking forward work in that regard.
Mr. Burstow made several observations about the performance assessment framework, as did Mr. Lansley, who said—this was a surprise to us, given everything that Dr. Fox has said in the past—that the Conservatives are not opposed to a national set of performance indicators. He provided the helpful clarification that although he was not against those indicators, he did not want anyone to rely on them too much. That is not a terribly sensible position for him and his party to adopt—perhaps we can look forward to further clarification of exactly what he means by it.
The hon. Member for Sutton and Cheam raised several issues that I shall try to deal with. He expressed his concerns about the 2003 star ratings and whether there had been any inappropriate ministerial interference. I quote to him what Deirdre Hine, the chairman of the Commission for Health Improvement, said on
"The targets and many of the indicators were set by the Department of Health but we have compiled the ratings this year. I would reiterate that there has been no pressure from ministers and these have been produced absolutely independently."
I hope that that deals with the hon. Gentleman's point.
The hon. Gentleman asked whether the final methodology that underpinned the eventual selection of performance indicators in July 2002 would be published. It was published on the same day as the performance indicators themselves—that is, nearly 18 months ago.
The debate has, predictably, generated a lot of heat, but very little light has emerged from any Conservative Front Benchers. I should therefore like to start by concentrating on the facts, not the hyperbole. Let us be clear about those facts. My right hon. Friend the Member for Darlington raised questions about the publications of the NHS performance ratings for 2002, and he was absolutely right to do so—any Secretary of State would have done precisely the same thing. At that time, the Department was responsible for the preparation and publications of those ratings, and my right hon. Friend was, rightly, accountable to this House for the work that was being done. Moreover, it was the first time that comparisons with a previous set of ratings were going to be possible, so it was entirely appropriate that he should be satisfied that the final assessments were fair and accurate, as some trusts stood to lose stars.
Most importantly, my right hon. Friend, in raising the questions that he did, was voicing the very same concerns about the 2002 ratings that had been expressed by NHS trusts. A significant number of NHS organisations—estimated at the time to be close to be half all those who had made representations during the ratification process—expressed concern about the inclusion of data from two performance indicators. The data on both were unreliable because there was confusion about what was being measured. That was the view of officials, who also advised that including the information from those two indicators in the final ratings could not be justified. The exclusion of the data from those two indicators was the sole reason why the South Durham NHS trust retained its three-star rating.
The two performance indicators dealt with access by doctors to the internet and access by patients to 24-hour catering facilities. Neither of those indicators, on any reasonable measurement, can be said to be so important that it should have been included in the final ratings, as neither was central to shedding light on NHS trust performance. That is why they were not used in 2002 and why neither was used in subsequent performance assessment exercises.
The hon. Member for Woodspring has repeatedly complained about the inclusion of such non-clinical data in NHS performance ratings. Far from criticising the actions of my right hon. Friend the Member for Darlington, as the hon. Member for South Suffolk chose to, he and his colleagues should welcome the fact that these two performance indicators were dropped from the 2002 ratings. Perhaps that welcome is being saved for another occasion, but I somehow doubt it.
My right hon. Friend also raised questions about the rating of eight other NHS acute trusts. In half those cases, no change at all was made to their eventual rating. That demolishes the central thrust of the Opposition attack that officials were somehow under orders to improve the star ratings of those trusts about which my right hon. Friend had expressed concerns. That is patently not the case. Equally untrue is the allegation that changes to the star ratings of individual trusts were made for political reasons. That argument has been comprehensively rebutted by the permanent secretary to the Department of Health—Sir Nigel Crisp made it clear today that he is satisfied that no such improper influences were brought to bear. In not accepting those assurances—indeed, in not even referring to them—Conservative Members are not only impugning the integrity of Ministers, but calling into the question the integrity of civil servants. I find that utterly contemptible.
The motion also calls for greater transparency in the use of performance indicators in the NHS. That is complete and utter hypocrisy. The Government have gone further than any previous Administration in providing the public with information about NHS performance. We want the public to know what is happening in the NHS and what use is being made of the initial investment. The policy that the Conservative party advocates would return us to the old days when there were no clear national targets for the NHS, and that would be unacceptable.
It is clear from the way in which the Conservative party has raised the matter that it has only one motive: to deny that any progress is being made in the NHS. That is its sole purpose. In the process of constructing that argument, it wants to help pave the way for its plans to expand the use of private medical insurance. That deeply reactionary and cynical policy would widen health inequalities, deprive the NHS of £2 billion of vital investment and set back its long-term expansion.
There is no substance to any of the allegations of wrongdoing that Opposition Members have made today. No evidence of impropriety has been disclosed; no misuse of power or authority has been established; no credible or convincing case has been made out that would lend any measure of support to any part of the interpretation of events that the Opposition presented. On that basis, I ask my hon. Friends to reject the puerile and fatuous motion.
Question accordingly negatived.
Question, That the proposed words be there added, put forthwith, pursuant to
Mr. Deputy Speaker forthwith declared the main Question, as amended, to be agreed to.
That this House notes that record investment in the NHS has to be linked to reform, and that this investment and the devolution of power to the front line require greater accountability; congratulates the Government on its record of making the NHS more transparent through the development of performance indicators; welcomes the Government's development of such indicators in consultation with patients and staff; congratulates the Government on giving responsibility for NHS performance monitoring to the independent Commission for Healthcare Audit and Inspection (CHAI), which reports direct to Parliament; and welcomes CHAI's commitment to developing new and more reflective indicators in partnership with representative bodies and the NHS itself.