NHS Next Stage Review

Oral Answers to Questions — Children, Schools and Families – in the House of Commons at 3:31 pm on 30th June 2008.

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Photo of Alan Johnson Alan Johnson The Secretary of State for Health 3:31 pm, 30th June 2008

With permission, I would like to make a statement on the final report of the NHS next stage review and the first NHS constitution. Before I do, I should like to pay tribute to my noble Friend Lord Darzi of Denham, who has led the process. He has done so magnificently, bringing to bear his invaluable professional experience and expertise. I thank him and the thousands of front-line clinicians who have shaped and formed the conclusions of his review.

As we celebrate the 60th anniversary of the NHS this week, it is befitting that we should acknowledge its successes, secure its strengths and chart a path for its future. Created by fraternity to take the place of fear, the founding principle of the NHS was as clear as it has been enduring: that access to health care should be determined by clinical need rather than the ability to pay. The NHS has been a friend to millions, sharing their joy and comforting their sorrow. Today, the service sees or treats a million people every 36 hours, eight out of 10 people see their family doctor every year and a million more operations a year are performed than 10 years ago.

Then, the NHS was suffering from chronic under-investment. The challenges were too few doctors and nurses, poor equipment and crumbling infrastructure. Patients waited months, if not years, for treatment; waited weeks, not days, to see their GP; and measured their time waiting in accident and emergency in days and nights rather than in hours. A service whose promise was fair access for all had witnessed patients dying before they could even receive its care.

This Government resuscitated the NHS and reaffirmed its principles. Today, patients wait no more than four hours in accident and emergency, and by the end of the year they will be able to go from referral by their GP to treatment—with all the diagnostic tests in between—in no more than 18 weeks, and normally in nine. There have been considerable improvements in the quality of care received by patients and delivered by NHS staff. The improvements for cancer and heart disease alone have saved nearly a quarter of a million lives in the past 11 years. The NHS is now able to deliver the highest quality of care in many medical disciplines and settings.

The report published today heralds the next stage for the NHS: to deliver the highest quality care for all. It is underpinned by the service's first constitution, which will empower patients by clearly articulating their many rights, bringing transparency to decision making, and securing its founding principles for generations to come.

The review has been led by front-line clinicians in every NHS region. Seventy-four local clinical working groups, made up of some 2,000 doctors, nurses and other staff working in health and social care organisations, have developed improved models of care for their communities, from maternity and new-born to end-of-life. They are based firmly on the best available clinical evidence and extensive engagement to ensure that they reflect the needs and preferences of local people.

In common with all health systems around the globe, the NHS faces some significant challenges: ever higher expectations; greater demand driven by demographics; the transformational power of better information; the changing nature of disease and treatment; and rising expectations of the health workplace. The report puts the NHS on the front foot, seizing the opportunities that those challenges present, rather than simply reacting to their consequences.

Meeting those challenges demands that the NHS do more to help people stay healthy and to give them more information, choice and control over their health and health care. Every primary care trust will now commission comprehensive well-being and prevention services to meet the specific needs of their local populations.

Preventing vascular conditions such as diabetes, stroke and coronary heart disease has the potential to save thousands of lives. Today, some 4.5 million people are afflicted by vascular conditions, accounting for more than 170,000 deaths every year. We will launch a new Reduce Your Risk campaign to raise awareness and understanding as a precursor to the national vascular screening programme for everyone aged 40 to 74 that will begin next year.

Improving the health of individuals and families will become an increasing focus for GPs. We will work with professionals and patient groups to improve the world-leading quality and outcomes framework to develop better incentives for maintaining good health as well as providing good care.

As much as the NHS will do more to help people to stay healthy, it will also become a service that responds more rapidly and effectively to the people who use it. Patients will be given more rights and control over their health and care. They will have greater choice of GP practices, with better information to make the best choices for themselves and their families. That will be delivered by a fairer funding system that gives better rewards to GPs who provide responsive, accessible and high-quality services. Choice will not simply be a policy of Government but a right secured for all through the first NHS constitution.

The constitution will guarantee patients access to drugs and treatments approved by the National Institute for Health and Clinical Excellence. We will give greater support to NICE to increase the speed of its appraisals process so that new guidance is consistently issued more quickly. Primary care trusts will have a new duty to provide transparency in their decisions and clear explanations to the public. Those measures proclaim an end to the postcode lottery in NICE-approved drugs and treatments.

The rights will be accompanied by more personal control for patients, harnessing their ingenuity to improve their health and care. Every patient with a long-term condition will be offered a personalised care plan, jointly agreed by the patient and a named professional, so that services are organised around the needs of individuals. For the first time, we will pilot personal health budgets that give individuals and families the fullest control over their care.

All the measures announced here today are designed to improve the quality of care that patients receive. It is essential that quality is understood from a patient's perspective. The measures pay regard to experiences as much as effectiveness, with safety as a given. Patients want to be treated in environments that are safe and clean, and to be shown respect and regard, compassion and kindness. The highest clinical quality can be undermined by letting the simple things slip.

We must have an unwavering, unrelenting and unprecedented focus on quality. Our approach will be dedicated and disciplined, putting quality at the heart of everything that the NHS does. We will begin by bringing clarity to quality, ending the daunting and frustrating confusion that is caused by the morass of standards. NICE will be transformed to select the best available standards, fill the gaps and establish a new NHS evidence service, which will ensure that best practice readily flows to the front line.

We can only be sure to improve what we can measure. Information can unlock local innovation by showing clinical teams where their greatest opportunities lie. We will create a national quality framework, so that every provider of NHS services systematically measures, analyses and improves its performance. Front-line teams will be supported by a new set of graphically illustrated quality measures that will inform the daily decisions that lead to improvement, known as a clinical dashboard. [ Interruption. ] I did not invent the title; clinicians did.

The power of information will be provided to the public. We will legislate so that all providers of NHS services will be required by law to publish quality accounts, just as they publish financial accounts, which will detail the quality of care that they provide for each and every service, and easy-to-understand comparative information will be made available online. For the first time, improvements to quality will be recognised and rewarded. Patients' own assessments of the success of their treatment and the quality of their experiences will have a direct impact on payments.

We will harness the expertise and experience of clinicians, to raise standards by ensuring strong clinical involvement at every level of the NHS. New medical directors will be appointed to join existing nursing directors in every NHS region. They will be supported by clinical advisory groups to sustain and support the strong clinical voice elevated through the review. Nationally, a new quality board will be formed to provide leadership, advise Ministers on top clinical priorities for standard setting and make an annual report on the state of quality in England compared with that of international peers. There will be strong safeguards for quality, with no hiding place for those who fail to get the basics right on issues such as infection. I have already announced that the Care Quality Commission will have tough new enforcement powers to tackle infections and other lapses in patient care.

Finally, we know that health care works at the edge of science, constantly creating new ways to cure and care for patients. The NHS has long been a pioneer, but too often too few NHS patients have benefited. We will create an environment in which excellence and innovation can flourish. That is why the report heralds new partnerships between the NHS, universities and industry to achieve the very best care for patients. This ambitious agenda to improve quality for patients can succeed only by unlocking the talents of the front line. We will ensure that NHS staff have the freedom to focus on quality, empowering them to improve services.

Clinicians have abilities that go beyond clinical practice alone. Our new expectations of professionalism redefine their role as practitioners, partners and leaders in and of the NHS. We will unlock clinicians' creativity and innovation, give greater responsibility for the stewardship of resources and proclaim a new obligation to lead change where the evidence shows that it will improve quality.

These noble objectives will be supported by pragmatic action. Our journey of setting the front line free from central direction will continue, our commitment to foundation trusts remains strong and we will extend similar freedoms to community services. We will free up their talents by introducing a right to request to set up a social enterprise. All primary care trusts will have an obligation to consider these requests, and staff choosing to join such organisations and continuing to care for NHS patients will be able to retain their NHS pensions.

With greater freedom will come a newly enhanced accountability. The report sets no new targets; our approach will be openness on the quality of outcomes achieved for patients, meaning accountability for the whole patient pathway, from beginning to end. NHS staff are the service's most precious asset. We will more clearly illuminate how highly we value them by making new pledges to all staff in the NHS constitution: on work and well-being; on learning and development; and on involvement and partnership. All NHS organisations will have a statutory duty to have regard to the constitution.

Furthermore, the system for education and training will be reformed by working in partnership with the professions. We will open a new chapter in our relationship with the medical profession by establishing Medical Education England. We will increase our investment in nurse preceptorships threefold, so that newly qualified nurses will be given more time to learn from their senior colleagues. We will pay higher regard to the contribution of non-clinical staff—the porters, administrators and others who are the backbone of the service—by doubling our investment in apprenticeships, and we will strengthen arrangements for learning and development so that all staff have access to the opportunities that they need to update and enhance their skills. Following today's publication of the final Next Stage Review report, we will over the course of this week publish supporting documents that set out in more detail our proposals on primary and community care, for the work force and for informatics.

Finally, let me turn to the first NHS constitution. The changes outlined by the review will improve quality, but the best of the NHS—its enduring principles and values, and its defining rights and responsibilities—must be protected for generations to come. Patients and the public should be empowered by the clear expression of their rights in relation to the NHS, and the value of staff should be fully recognised. Decision making should be transparent and accountability strengthened. It is right and proper that a national health service, funded by national taxation, should remain accountable in and to Parliament. These goals are accomplished by our draft constitution, which we will publish for consultation today.

Our proposal is to legislate so that all NHS bodies, and independent and third sector providers of NHS services, must take account of the constitution in their decisions and in their actions. The Government will be required to renew the constitution every 10 years, involving the patients who use it, the public who fund it, and the staff who work in it. No Government will be able to erode or undo the fundamental basis of the NHS without the consent of the people's elected representatives.

Safe in the knowledge that the best of the NHS shall not perish, we will pursue our ambition to deliver the highest-quality care to all—not in some respects, not in many respects, but in all respects. On its 60th anniversary, after a decade of investment the NHS has the most talented array of staff in its history, united in their ambition. High-quality care for all is now within our reach. The report charts a path towards its achievement, and I commend it to the House.

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Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

The 60th anniversary is a time to thank the staff of the service. It is a moment at which we should reiterate the values of the NHS, which command support on both sides of the House. We should also ensure that the NHS is fit for purpose in the 21st century. This is an opportunity to show vision and leadership for the NHS. It is a chance to create an NHS that is genuinely patient-centred and evidence-based.

Regrettably, however, the work of the clinical pathway groups around the country has been overlaid by a continued bureaucratic, top-down system. In place of vision, we get another list of initiatives: some old, some new, some borrowed, and quite a lot of them blue. The vision should be that we raise the quality of health care in this country so that it becomes among the best in Europe. Our cancer survival rates are below the European average, our mortality rates from heart disease and stroke are above it, and our lung disease mortality rates are truly shocking. While focusing on that vision and holding the NHS to account for patient outcomes, we must at the same time set the NHS free from distorting top-down process targets.

The Secretary of State, however, is confused. He says that there will be more outcome measurements, but no new targets—yet he clings to all the existing targets, and the policy will not work unless it is geared to outcomes. If managers are still geared to targets, they will continue to distort clinical decisions in pursuit of them. If the Secretary of State does not propose to scrap the targets, how can we believe that the outcome measurement will drive the policy? Yet he says nothing about scrapping those targets. Clearly, other parts of the Blairite agenda have been dropped, as there is nothing in the statement about practice-based commissioning, foundation trusts or independent sector treatment centres. If they are all on the back-burner and the Blairite agenda has gone, why does the Secretary of State cling to targets?

The Government have followed our lead in proposing an NHS constitution, but where in that is the incorporation of NHS values? Why have two of the NHS principles set out in the NHS plan—continuity in respect of those principles would help the NHS—gone missing, including the principle that the NHS will support and value its staff? If it is a real constitution, where are the definitions and duties of NHS bodies; and where is the operational autonomy and independent regulation so essential to a more autonomous and patient-centred service? A constitution needs to be more than a patients charter, important as such patients' rights are. If the NHS continues legally to be whatever the Secretary of State decides it is, the power will still live in the Department of Health, which is clearly what the Department of Health intends.

Will the Secretary of State look again not so much at these documents today, but at the performance regime document that he published last month? It describes strategic health authorities as

"the local headquarters of the NHS" and it gives them power to control their areas. We can see what that means, as the Darzi review document proposed 21 new bodies at a regional level for the East of England SHA. The Secretary of State talks about local decision making, so will he stop the regionalisation of the NHS and the growth of a new regional bureaucracy on top of everything else?

The Secretary of State proposes to create Medical Education England, but he views it as an advisory body, not as the body responsible for commissioning medical education and training to meet work force needs, as agreed between health care employers and staff. The real power of commissioning is given to—guess who—the strategic health authorities. The plan claims to be bottom-up, so will the Secretary of State abandon the top-down insistence on polyclinics and let the local NHS decide how primary care services are best provided? How can the Secretary of State talk about GP access and then want to shut down local and accessible GP surgeries? Clinicians care about continuity of care, so why do the Government undermine it?

On health care-associated infections, where is the zero-tolerance strategy that patients are demanding? If the South East Coast SHA can pledge in its Darzi review that there will be no avoidable cases of hospital-acquired MRSA by 2011, why cannot others? Why are C. difficile rates in the UK 10 times those of other health economies?

Apparently, the Government are claiming that they will promote home births. How can that be so when 15 local maternity units have been closed or have lost their obstetric service and 26 more are threatened? The simple fact is that if obstetric care is taken further away, home births or birth centres simply cannot be offered.

The Secretary of State has followed our lead in a number of areas: extending personal budgets to include some patients with long-term conditions; enabling palliative care patients to choose where their care is provided; and publishing more data on outcomes reported by patients. Let us be clear about outcome measurement. Mortality rates for hip replacements are of limited value. Patient-reported outcomes need to extend to subsequent information on mobility, return to work, ability to look after oneself and absence of pain. Narrow outcome measures are only a little better than narrow targets.

The Secretary of State said nothing about public health services. Obesity, binge drinking, drug misuse and resurgent infections threaten our health and the future of the NHS. Health inequalities are widening. Improving public health is critical to long-term health outcomes and the ability of the NHS to meet demands successfully. The lack of preventive action is a scandal, yet no response in today's statement is remotely proportionate to the challenge.

The Secretary of State also now says that patients will not be subject to a postcode lottery. How often have Members heard that? Time and again. In reality, there is nothing new in what he announced today. It is already the case that primary care trusts should not refuse access to drugs on cost grounds alone while awaiting evaluation from NICE. If NICE approves a drug, they are already obliged to make it available within the NHS within three months. Last year, the Government promised to speed up NICE evaluations, yet today we are still among the countries with the slowest uptake of new medicines, despite being world leaders in research.

We thank all those who have contributed to the review. The local clinical work will be valuable, but we must regret the fact that the Government appear unable to recognise that quality in the NHS depends on responding to patients' needs and expectations, the exercise of choice within a competitive environment, the freedom to innovate and a focus on the importance of outcomes for patients. It does not require—indeed, it will be impeded by—top-down process targets, excessive bureaucracy, incoherent policies and a command-and-control approach.

Modern health care demands that we free the NHS to deliver outcomes and quality for patients. That is the best diamond jubilee gift we could give to the NHS.

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Photo of Alan Johnson Alan Johnson The Secretary of State for Health

I am very disappointed by that response, particularly as so many clinicians—not just the 2,000 who have been working with Lord Ara Darzi, but 60,000—have had an input into this. Those visions, for which today's final report from Ara Darzi is the enabling report, were developed locally, not dreamed up in a strategic health authority. The hon. Gentleman attacks it on the basis that there is too much top-down bureaucracy—

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Photo of Alan Johnson Alan Johnson The Secretary of State for Health

The hon. Lady says that there is, but this is an example of our having freed up clinicians and people working in the health service, patients and carers, the staff and the public to set out their framework for the future.

Mr. Lansley says that we should scrap the targets. The position of Conservative Members is that there should be no greater access to GP surgeries, no 18-week maximum wait for surgery and no maximum of four hours in A and E. He mentioned the patients charter. I have the patients charter in front of me. What does it refer to? This, after 16 years of Conservative government:

"For hip or knee replacements and cataract operations, a waiting time guarantee of 18 months".

It was signed by Baroness Bottomley in 1995. What did the Conservatives go on to say? They said:

"From April 1995, the NHS is broadening" this

"to cover all admissions to hospital."

[Interruption.] The point is that we could have done with someone setting some targets, getting to grips with the issue, before we came into government, but that is the best that they could offer after 16 years in power— 18 months of waiting.

The hon. Member for South Cambridgeshire also said that we followed the Conservative lead on the constitution. I am sorry, but I have traced this back to a Fabian pamphlet produced by my right hon. Friend who is now the Secretary of State for Culture, Media and Sport long before the ideas from the Opposition were put forward in relation to this independent NHS. They want the NHS to be a giant unelected quango—an idea that was ridiculed again this week by The Lancet, as well as by the King's Fund and every other organisation that has looked into it.

The hon. Gentleman then said that we should have bottom-up solutions. Polyclinics were developed in London by London clinicians, in a part of the world where 54 per cent. of GPs are either single or double-handed, where a third of all practices do not even have disabled access and where 50 per cent. of A and E cases involve people who should be in primary care.

The Opposition reject a local solution enabling GPs to come together in services that can provide diagnostics, blood tests and X-rays, or to stay in their own services while being linked through a hub-and-spoke system. It is preposterous that the Opposition should oppose a move envisaged by Bevan in 1948.

The hon. Gentleman spoke of maternity units. For the first time in 40 years, we stood up for clinicians in Manchester who said that three large neonatal specialist units were needed at the expense of four other units in the area. That will save the lives of between 30 and 40 babies a year, and will cost an extra £60 million. The Opposition were first against it and then for it, but the reconfiguring of services means that clinicians are able to say "This is how best to improve patient care". Although the Opposition's response is disappointing, it will not stop us from working with clinicians, staff, patients and carers to improve the quality of care in the NHS.

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Photo of Norman Lamb Norman Lamb Shadow Secretary of State for Health, Liberal Democrat Spokesperson (Health)

I thank the Secretary of State for early sight of his statement. It contained much in terms of aspiration on which we can all agree—it refers to the pursuit of quality and prevention in health care, access to medicines and the importance of empowering patients—but the main issue is how those goals can be achieved. There was little, if anything, in the statement to suggest that the Government have learned that change cannot be dictated from Whitehall.

I was given a copy of the original leaflet informing the public about the national health service back in 1948. It contains a section about health centres, which states:

"Doctors may be accommodated there instead of in their own surgeries".

I suppose that what goes around comes around, but is not the current imposition of GP-led health centres, or polyclinics, yet more evidence that the Government have not learned that this issue cannot be approached through command and control from Whitehall?

The Secretary of State has previously acknowledged the democratic deficit and lack of accountability in the health service. He is still the only democratically accountable person in the service: nothing has changed as a result of his statement. Have they got to him, or does he still acknowledge the democratic deficit in the NHS?

We strongly agree about the need to speed up access to drugs and to speed up the NICE process, but what about all the drugs already on the market that have not been NICE-approved? It seems to me that the postcode lottery will remain with a vengeance in the case of all the drugs that came on to the market before NICE existed. Does the report contain any proposals to examine the criteria that NICE applies in deciding whether to approve a drug? It is currently not possible to take into account the interests of carers and others in relation to dementia drugs, and despite a recommendation from the Select Committee on Health, there was nothing about that in the statement.

As for the constitution, although I endorse the case for clarity on rights and responsibilities, will patients be given legally enforceable rights or is this a "motherhood and apple pie" statement of ultimately meaningless intent? What will be done, for example, to end the scandal of the mixed-sex wards that still exist in our hospitals, particularly in the mental health sector?

I am very concerned about the lack of any reference to mental health in the statement. The Secretary of State will be aware of yesterday's devastating analysis of the state of mental health services by the new president of the Royal College of Psychiatrists. The 18-week target is absolutely irrelevant to anyone with a mental health problem. Can it be right for this to continue? Is it not bizarre that patients will have a legal right to a drug to suppress their condition, but no right to the treatment that could cure them? Surely that is ridiculous.

The statement also made no reference to tackling the health inequalities that scar our country to this day, and appear on many indices to be worsening. Is that no longer a priority for the Government? Surely if it were a priority, it would have been headlined in the statement.

The statement contained much good rhetoric—and much good new Labour rhetoric, such as the reference to a "clinical dashboard". I was, at least, relieved that the Secretary of State denied any responsibility for that ludicrous concept. The proposals have good aspirations, but also some notable and serious omissions. One is left with the sense that, when the dust has settled, nothing much of significance will change.

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Photo of Alan Johnson Alan Johnson The Secretary of State for Health

The hon. Gentleman at least damns the proposals with faint praise. He is wrong about dictating from Whitehall. There has been an ongoing debate about that within the NHS for 60 years. The original concept of the NHS—this was also central to the debate within the Cabinet at the time between Morrison and Bevan—was that hospitals should be taken out of the control of local municipalities and charities. Bevan's vision for the national health service was one that, in a sense, needed to be driven from the centre. I accept, as we all do, that what we are discussing today is not simply a question of providing more autonomy, but of how we do that in a system that we might describe as one of subsidiarity, in which the centre still has a responsibility through elected politicians to ensure that, for instance, waiting times and health care-acquired infections are tackled and that pay is determined centrally. What the public said time and again as we went through this process is that, in terms of health, they are not as concerned about devolving to the local level as they are about ending the postcode lottery and of having a more uniform system from the centre. That is what the debate is about.

The hon. Gentleman talked about accountability. In terms of the constitution—I think this is what he was referring to—we looked at whether we should impose greater accountability on primary care trusts. In the end, we decided that a lot is happening at the moment and we should not impose something from the centre, and I was delighted to discover that the Local Government Association—it set up a commission on which Mr. Dorrell, a previous Secretary of State, sat—came to the same conclusion. It said:

"On balance, further restructuring of PCT boards or changes to" their

"responsibilities...would be an unfortunate distraction and likely to do more harm than good in the short to medium term".

We agree. That is not to say that what is happening in terms of accountability—foundation trust models, councillors sitting on the local board of the PCT—should not continue. We just should not impose something over the top from the centre.

When the hon. Gentleman reads the document, he will see that it covers some of the matters he referred to, including the clinical dashboard—which I assure him surgeons and clinicians love, so those who wish to interfere with it, do so at their peril. He mentioned health inequalities. First, it is important to mention—as Professor Michael Marmot, the world-renowned expert on this, points out—that the health of everyone in the UK has got better. If the basis had been just the health of the poorest improving in terms of life expectancy and infant mortality, we would not just be closing a 10 per cent. gap, but we would have closed the gap completely since 1997; but, quite rightly, the health of other, more prosperous, groups has improved. We published the health inequalities strategy two weeks ago. There is a reference to the minimum practice income guarantee, which is important because that militates against health inequalities.

On mental health, all the eight clinical pathways from maternity through to palliative care looked at mental health as well, and mental health also had its own group. Also, in all the 10 reports from each of the regions around the country, mental health is dealt with in terms of the right for people with long-term conditions to have a care plan, the right to get much better practice into local and community practice and the right for patients to be empowered over their own care. That applies to mental health as much as to any other form of illness.

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Photo of Ronnie Campbell Ronnie Campbell Labour, Blyth Valley

I welcome the statement, but may I ask about the polyclinics and their relationship to general practitioners? In my area, they wrote an open letter to the local newspaper criticising the polyclinics. I think they are a pretty good idea, but how are we going to get the GPs to work with the polyclinics, because many people do not realise that they are private operators within the health service?

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Photo of Alan Johnson Alan Johnson The Secretary of State for Health

Norman Lamb mentioned the 1948 leaflet that went through every door and that said that health centres would come eventually. They never did, either through lack of funding or professional opposition. What would really help would be to get away from the deliberate misconception about these centres. The first argument is that they will all have 25 GPs. They will not—they will have about five. The second argument is that people will have to leave their own GP to go there. Wrong—people can go to one of the GP-led health centres and still remain registered with their GP. The third argument is that they will all be run by private companies. Obviously, there is a tendering process and we want to see quality, particularly in under-doctored areas, where we are increasing the number of GPs to provide a proper service. However, we expect the vast majority to be run by GP consortiums. Once people see that all these dreadful distortions—in part, exaggerated by the Conservative party—are just not true and that we are increasing capacity, they will see that this is a frankly long overdue increase in capacity in primary care.

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Photo of Iain Duncan Smith Iain Duncan Smith Conservative, Chingford and Woodford Green

One reason why people in my area of Waltham Forest are very resistant to any of these new plans is that, rather like many other people, they have just survived a "fit for the future" programme that was a disaster, in which the PCT managers rode roughshod over all the public's views and attempted to close down one of their hospitals. That was stopped eventually, such was the outcry, but they remain very sceptical about this.

For example, people are told that, in north-east London, stroke centres will save lives, but we know now from clinicians that unless someone gets to a stroke centre within two hours and starts the treatment, it will have no further effect on them and they might as well be at their local hospital. Given the problem of diagnostics, is not the reality that this will not apply at all to the majority of stroke victims?

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Photo of Alan Johnson Alan Johnson The Secretary of State for Health

I am sometimes confused whether people want central command and control. The one consistent thing through all 10 SHA reports is the need to specialise in heart disease, stroke disease and serious traumas. Now, right across London and around the country, there is a real focus, and the stroke strategy that we published in December was probably the most widely welcomed Government health document that we have ever seen. Indeed, the hon. Member for South Cambridgeshire praised the philosophy behind it. So it is no good pretending that people will get as good stroke care in hospitals where the clinicians experience these problems only once in a blue moon. They need specialist care, and that is how we are beginning to bring down the number of deaths from strokes and to ensure that we compare favourably with all the health services in Europe.

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Photo of Brian Iddon Brian Iddon Labour, Bolton South East

Between the poorest parts of my constituency and the better-off parts of Bolton, there is 15-year mortality gap. To address that problem, Bolton PCT has just launched a major programme to screen by March next year all 45-year-olds—44,000 altogether—who have not had basic health checks recently. Will my right hon. Friend send Bolton PCT his congratulations, along with mine? In 1997, its precursor would not have had the resources that it has today to carry out such programme.

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Photo of Alan Johnson Alan Johnson The Secretary of State for Health

I send my congratulations to Bolton PCT. Again, here there is a mix between what is done nationally—for example, the smoke-free legislation that we introduced a year ago, which was not an easy decision to make—and the action that takes place locally. In my hon. Friend's constituency and mine, we see terrific initiatives to tackle deeply entrenched problems of health inequalities. I congratulate Bolton PCT and all the other PCTs across the country that are getting to grips with this issue.

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Photo of Patrick Cormack Patrick Cormack Chair, Northern Ireland Affairs Committee, Chair, Northern Ireland Affairs Committee

What does the Secretary of State's statement offer in the way of hope for a more human and humane service to the cancer patient in my constituency who received the most appallingly cold and bureaucratic letter telling him that he cannot have the drug? When he wants to see a doctor in the middle of the night, someone comes and, with satellite navigation, eventually finds their way to the house but has no knowledge of the patient and little knowledge of the language. What does the statement offer that man?

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Photo of Alan Johnson Alan Johnson The Secretary of State for Health

The hon. Gentleman touches on some of the issues. Irrespective of what else happens in the NHS, his constituent will feel let down by it. There will always be treatments that do not go through the NICE process or are still undergoing the appraisal process. In those circumstances, it is up to the PCT to make a decision. What we say in the constitution is that a patient now has a right to a proper explanation of why a treatment has been denied. They also have the right to ensure that they are treated with dignity, respect and compassion. Those things can be measured. The press were talking about the size of a nurse's smile, but the Royal College of Nursing supports us on this because although safety and effectiveness can be measured, compassion and dignity are equally important to patients' experience. We can measure those factors through patient surveys and ensure that the quality of care improves for everybody.

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Photo of Clive Efford Clive Efford Labour, Eltham

I welcome the statement and the fact that my right hon. Friend has reiterated that future Secretaries of State will remain responsible for the framework and accountable for the future of the NHS. The Opposition seem to want to do away with national targets, but can he explain how we could set a national framework without targets? Does he ever envisage a day when a Secretary of State will come to the Dispatch Box and say, "It's not my fault, mate: it's all the local people taking decisions."? What is being proposed is a free-for-all in the NHS, which is where we were in 1997, when we had an internal market that did not provide a consistent service across the country, and passports that would have taken money out of the NHS to subsidise the private sector. It is only this Government who are protecting the NHS and only a national framework that will do so.

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Photo of Alan Johnson Alan Johnson The Secretary of State for Health

My hon. Friend is right. Waiting times were the major concern in every survey. Patients were dying on waiting lists of more than two years. I have quoted the best that the Conservatives could do after 16 years in government—it was a disgrace. Getting hold of that situation and reducing waiting lists to an average of nine weeks—and a maximum of 18 weeks—for all the diagnostic tests and so on by the end of this year will be a major achievement. Of course we need to ensure that the NHS is clinically led and locally driven, but that does not release me as Secretary of State, or us as a Parliament, from our responsibility for ensuring that we have a national health service providing a uniform quality of care across the country.

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Photo of Kenneth Clarke Kenneth Clarke Chair, Tax Law Rewrite Bills (Joint Committee)

Ever since the Labour Government were converted to the principles of reform, Ministers—including the present Secretary of State—have expressed support for patient choice and competition between providers. Can the Secretary of State reassure me that he is not moving away from that by now insisting on using the words "empowerment" and "transparency", and adding a load of management consultancy jargon and the legalism of a constitution written by whoever prepared his statement for him today? If he wishes to make a reality of local patient-based services, why not just give GP practices more control over commissioning and implement practice-based budgeting? If he wants polyclinics to emerge, which they could with some benefit in London and parts of big cities where there is an obvious need for them, why does he need a centrally managed national plan to impose them—and use resources—in areas where there is not the slightest evidence of local demand or need?

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Photo of Alan Johnson Alan Johnson The Secretary of State for Health

For two reasons. First, for 60 years we have had the bizarre and perverse result that there are half as many GPs per head of population in the poorest areas. That is Dr. Julian Tudor Hart's inverse care law, under which the people who need the care most are least likely to get it. We are not putting up with that any more. Putting new GP services in the 25 poorest communities in the country will tackle health inequalities, and it is essential that we do that— [Interruption.] Opposition Members say that that would have happened anyway, but it did not happen in 60 years. Incidentally, on the second point, neither has there been a GP service that patients can access from 8 am to 8 pm, seven days a week, 365 days a year. Yes, I plead guilty to saying that we should provide the funding from the centre to ensure that that happens. It has not happened since 1948, because of either a lack of funding or professional opposition. The "Anne of Green Gables" idea that if we just hand over the money to the British Medical Association it will ensure that that change happens is, frankly, ludicrous.

My final point to the right hon. and learned Gentleman is that there is more than one word to use. We use the simple word "choice", as I hope that he will see, over and over again in the constitution. Practice-based commissioning needs to be developed further, and that is part of the review, but the real issue of choice comes down to the patients. We are introducing, for the first time, an element of the tariff that will be based on quality. That is an important development to drive quality through the system.

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Photo of Mary Creagh Mary Creagh PPS (Rt Hon Andy Burnham, Secretary of State), Department for Culture, Media & Sport

My right hon. Friend's national vascular screening programme will be of great interest to my constituent, Kath Howitt, whose husband Glen died two years ago, very suddenly, at the tragically young age of 39 with undiagnosed high blood pressure. Will my right hon. Friend ensure that the tendering process for the new GP services will not be over-burdensome and will allow innovative social enterprises, such as Local Care Direct, which offers out-of-hours GP services in Wakefield, to increase their scale and reach? Will he ensure that the tendering process allows a level playing field and does not hinder such initiatives?

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Photo of Alan Johnson Alan Johnson The Secretary of State for Health

I am sorry to hear about my hon. Friend's constituent. Of course, it is crucial to have this screening programme for everyone—men and women from the ages of 40 to 74, with a call and then a recall every three years. When we announced it, there was only one dissenting voice—the representative of the BMA, who said, "We don't have the capacity." Now we are providing that capacity, not just for that condition but for abdominal aortic aneurysms, which are one of the biggest killers of men over 65. I can assure my hon. Friend that the services will be properly tendered and will allow social enterprises, pharmacies and others to compete, although the majority of the screening programmes will take place in GP's surgeries.

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Photo of Richard Taylor Richard Taylor Independent, Wyre Forest

May I welcome the emphasis on quality, and particularly on compassion and kindness? The debate in the House on 17 June on polyclinics cleared the air very well and told us exactly what GP-led health centres will have to provide. It also made it clear to me for the first time that existing GPs could bid for those services. It has come to my notice that the offers of bidding have closed in some PCTs before general practices have been aware of them. Is there any way by which the length of time can be extended so that GP practices can tender on a level playing field?

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Photo of Alan Johnson Alan Johnson The Secretary of State for Health

Ironically, it was the Opposition who gave us the opportunity to clarify the situation by going against the propaganda that they had been putting out. I am happy that the hon. Gentleman saw that clarification. Only one contract has been awarded, and that was awarded to a social enterprise. We expect the vast majority to go to GP consortiums and there is no way that those consortiums have anything other than a level playing field as regards bidding. If the hon. Gentleman has any details about where he believes that there has been a problem, and if he writes to me, I shall look into it and try to ensure that the proper procedures take place.

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Photo of Lynne Jones Lynne Jones Labour, Birmingham, Selly Oak

May I ask my right hon. Friend how greater choice and control over health care will be extended to groups that are sometimes very vulnerable, such as people with mental health conditions, and those for whom society has generally had less sympathy, such as people with gender dysphoria? On the subject of mental health wards, may I invite my right hon. Friend to join me and visit the brand new in-patient facilities that have recently opened in south Birmingham, of which we are very proud?

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Photo of Alan Johnson Alan Johnson The Secretary of State for Health

I will very gladly come and look at the new facility in south Birmingham. It is important to point out that we must ensure that mixed-sex accommodation is eliminated in mental, as well as physical, health facilities. On the issue of mental health, as I said earlier, there was a specific pathway—one of the "pathways of care", as they are termed in medical circles—on mental health. When my hon. Friend has had a chance to look at the report, she will see that the result, particularly in her area, is that there will be a complete focus on ensuring that if people are incapacitated to such a degree that they are not able fully to control their own destiny, they will have someone with them—an advocate—to make sure that the right decisions are made. As the World Health Organisation keeps saying, there is no physical health without mental health. In the report, mental health is as important as any other aspect of health.

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Fine but nothing said about gender dysphoria.
John Nightingale

Submitted by John Nightingale

Photo of Phil Willis Phil Willis Chair, Innovation, Universities, Science and Skills Committee

I was a little concerned about the fact that the right hon. Gentleman did not mention the ambulance service at all in his statement. A week ago, one of my constituents called for an ambulance at 7 o'clock; by 8 o'clock, when an ambulance eventually arrived—all the ambulances were in York and Scunthorpe and were not available—she was dead. What does the Secretary of State have to say to her family, and to others who do not get the care that they need simply because there is no ambulance available for them?

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Photo of Alan Johnson Alan Johnson The Secretary of State for Health

I very much hope and trust that that is an exception to the normal rule, and I will look into the circumstances of that case if the hon. Gentleman would like me to do so. Ambulance services and paramedics are a crucial part of the report. When he has had a chance to look at it—I appreciate that we are talking about 10 SHA visions in every region of the country, and by an enabling report by my noble Friend Lord Darzi—he will see that the issue is crucial to ensuring quality. Paramedics and ambulance staff are even more important now, particularly as regards stroke care, which we talked about earlier. Care for a stroke patient should start at the moment when the ambulance arrives, not when the patient gets to hospital.

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Photo of Gordon Prentice Gordon Prentice Labour, Pendle

My friend told us that NHS staff will be able to leave the organisation and subsequently contract with it as members of a social enterprise. How many people does he think will take advantage of that offer in the next year or two, and what are the advantages of going down that road, both for the national health service and for groups of former employees?

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Photo of Alan Johnson Alan Johnson The Secretary of State for Health

I am not sure how many people will take up the offer. There are already three or four social enterprises across the country. When we went through the process, we found that lots of front-line clinicians, including midwives, nurses and physiotherapists, wanted to link together and set up their own organisation—and sometimes to move into adult social care as well—to avoid the bureaucracy sometimes involved in different NHS organisations working together. What stopped them was the fact that they wanted to preserve their pensions. For instance, people providing sexual health services in my patch, Hull, told me just a couple of weeks ago how much more they could do if they could set up their own organisation.

Today, we are saying that PCTs that are being difficult on the issue will have to treat a request from staff seriously. If the change goes ahead, staff will retain their NHS pensions. In addition, for the first three years, the contract will not go out to tender; the people involved will be guaranteed a clear run. I believe that lots of providers across the country will be keen to take up the suggestion. The unions are very keen for us to go a step further and ensure pension portability everywhere. That is much more difficult. Ensuring that portability in social enterprises is easy; for the independent sector, it is very difficult.

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Photo of James Arbuthnot James Arbuthnot Chair, Defence Committee, Chair, Defence Committee

Forty per cent. of children who die of cancer die of a brain tumour, yet it takes longer to diagnose a brain tumour in this country than it does in many other countries in Europe, or in the United States. How will the review help to push brain tumours up the national health service's list of priorities ?

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Photo of Alan Johnson Alan Johnson The Secretary of State for Health

Once again, when the right hon. Gentleman has had a chance to look at the eight clinical pathways, one of which included the issues of paediatrics and children's care, he will see that there are some really important developments. Strategic health authorities and local clinicians are saying, "If we were empowered to do things differently, we could improve services and do what we need to do, not just nationally, but locally." There is a clear concentration on improving children's health as part of that clinical pathway.

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Photo of Tom Levitt Tom Levitt Labour, High Peak

The modern equivalent of outright opposition to the NHS in 1948 is the professional cynicism that we hear today from the Opposition and, indeed, from some parts of the medical profession. Does my right hon. Friend not agree that some doctors—some, only a few—talk as if healthier patients are a threat to their livelihood? Will he assure me that over the next few days and weeks he will spend his time not in defending the health service but in proselytising the advantages that it brings to patients, communities and the people who work in it?

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Photo of Alan Johnson Alan Johnson The Secretary of State for Health

I can proselytise for England, and will do so for the national health service, which is very precious. Yes, there are disputes, disagreements and so on with organisations and individuals but, basically, there is a huge buy-in to the next 60 years being even better than the past 60. I believe that we can work together with all organisations, whoever they represent, to make this vision work and improve patient care for everyone.

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Photo of Damian Green Damian Green Shadow Minister (Home Affairs)

The Secretary of State talked about GPs providing "responsive, accessible, and high-quality services", so will he take this opportunity to remove the axe that he has placed over the level of service provided by rural GP practices in my constituency that run their own dispensaries, which he plans to close down if there is a pharmacy near by? One of them has written to me saying that that would involve making redundant two salaried doctors, cancelling all phlebotomy services and discontinuing ECGs, 24-hour blood pressure monitors and 24-hour heart monitors. If he is genuinely concerned about GP services, why is he continuing with this mad plan?

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Photo of Alan Johnson Alan Johnson The Secretary of State for Health

That is myth No. 380 from the Opposition. What we have announced in the pharmacy White Paper is a consultation to look at dispensing pharmacies, principally because we need to ensure that patients have a proper choice. All the things that the hon. Gentleman mentioned in Hansard are absolute, complete, undiluted poppycock. We are not proposing any such thing. [Interruption.] Poppycock is the mildest word I could find. People should not be frightened of a consultation that concentrates, not on vested interests—I know that Opposition Members are absolutely imprisoned by vested interests—but on the good of the patient.

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