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Dr. Desmond Turner (Brighton, Kemptown): I give the Bill a hearty welcome, principally because I think it constitutes a genuine attempt to deal with a number of serious problems left by the last Government.
As always when I listen to the right hon. Member for South-West Surrey (Mrs. Bottomley), who was Secretary of State for Health in that last Government, I could not help but be amused. She spoke as though she had left us a garden of Eden, but we saw it quite differently. The Bill, as I have said, addresses problems left by her and other Conservative Secretaries of State.
Clause 6, which has not been mentioned, relates to terms and conditions. The national health plan makes a reasonable commitment to provide better and fairer rewards for NHS staff. The Minister knows that for some time we have been drawing to the Government's attention the plight of grotesquely underpaid members of staff. We have been particularly concerned about medical laboratory scientists who, until today, entered the service
I am happy--as is my union, the Manufacturing Science and Finance Union, which represents those people--about the double-figures, inflation-busting pay increases. That is great, but there is still an enormous gap. Those workers are poorly paid by the standards of comparable professions. However, that is a good start and we are grateful for it, but it has not solved the problem.
How will the provisions in clause 6 help to address such issues in future? Are the Government going to do something about the decoupling that the previous Government undertook many years ago when they removed many groups of NHS workers from the remit of the pay review body?
Mr. Denham: The purpose of clause 6 is to enable us to ensure that the outcome of the "Agenda for Change" negotiations, which are taking place with trade unions, will apply to all health service employers. We do not have the power to do that under existing legislation. My hon. Friend will be aware that "Agenda for Change" deals with the issue of membership of the pay review body. However, trade unions in general welcome clause 6 because it will mean that the national framework for pay and conditions, which was destroyed by the previous Government, will be available for NHS employees. The Government and the unions have sought the reintroduction of that framework.
As for the democratic deficit, I believe that the Opposition are keeping a score. It is possible to add another name to the people who are happy to see the CHCs abolished. I, too, speak as a former member of a CHC. Although it is true that many of them have done good work, the one that I served on did not. I got off it as quickly as I could because it was a totally ineffective knitting circle. It was not helped by the fact that it had virtually no statutory powers, because they had been eroded. It was a bit of a dead letter. I feel that there is tremendous merit in returning local authorities to a scrutiny and accountability role in respect of the national health service. A council scrutiny committee will punch with greater weight and do much more incisive work, so the development should be welcomed.
I am also happy with patient advocacy services, which are an absolute necessity as the current NHS complaints system is woefully inadequate. Currently, it is almost voluntary for a health authority or trust to respond to complaints. It does not have to grant a hearing unless it feels like doing so. That is wrong. If a complainant is unsatisfied, he or she should be entitled, as of right, to a full hearing at some form of independent tribunal. When we hear the detail of the proposals, I hope that we will be assured that such a structure will be introduced. I shall not join the chorus of defence for CHCs. It is interesting that such support should come from the Opposition, who were happy when the CHCs could not do much about
I am much more concerned about long-term care. Although I welcome the proposal for free nursing care, I, too, think that it should extend to personal care. I do not accept the Ministers' view that there is a clear and simple division between personal care and nursing care. For example, it is extremely difficult to make that distinction in respect of Alzheimer's sufferers. Indeed, the Secretary of State undermined the principle by saying that he would extend the coverage of nursing care. In what manner and by how much? Clearly, there will be opportunities for arguments, bureaucratic mistakes and vast amounts of assessment and reassessment, and hard cases could be thrown up. The proposal throws into question the financial imperative.
It is clear that the Government have a problem--or, at any rate, a perceived problem--with fully implementing the Sutherland proposals and with instituting free personal care because of the cost involved. The Sutherland report shows that the difference between the extra cost of providing free personal care and of providing only nursing care would be 30 per cent. by the year 2050. All such calculations and predictions are fraught with danger. The range of possibilities means that it is difficult to be precise. The fact that the Government's proposal on nursing care extends more widely than the matters considered by the Sutherland commission when it made its calculations suggests that the difference in cost between nursing care and personal care may be less than the commission envisaged. Obviously, the cost is substantial; nobody would deny that. Meeting the cost of nursing care alone is a substantial and welcome commitment. However, I beg the Secretary of State to reconsider the personal care issue.
It is probably possible to encompass personal care in reasonable spending predictions and to deliver it. That would have the great merits of simplicity and fairness. It would save an enormous amount of administration in determining what is and what is not personal and nursing care. Anything that involves intimate body contact would be covered. The definition would be much simpler to operate and therefore much less likely to create hard cases. That is my instinctive view, having spent years as a councillor helping to run social services as a politician, but it is also a professional view.
I tend to talk mostly to directors of social services and it is their view as individuals that such distinctions are not easy and are fraught with difficulty. I am told that the Government should not be totally satisfied with the response of the Association of Directors of Social Services, which appears to acquiesce to the Government's proposals, because a poll of directors of social services across the country would reveal a majority very much in favour of making personal care free. I think that that is the only fair thing to do. The proposal on personal care is the greatest flaw in an otherwise fine Bill. It needs a lot more careful thought. Providing free personal care is achievable, and, if we managed to do so, we would leave a reasonably proud inheritance to the nation.
I believe that the Scottish Parliament is to do just that. It thinks that it is possible to institute free personal care without having to resort to increased taxation, and proposes to do so. I therefore again ask the Secretary of State to look very long and hard at that question once
The rest of the proposals for dealing with the mess of community care are very welcome, although it will obviously be vital to know exactly how far the capital limits for disregard will be raised and other details of the financial regulations that will follow.
Despite those three areas of concern--the first of which the Minister has answered to my satisfaction--I warmly applaud the Bill, although I hope that the Secretary of State will think very hard about personal care.
Mr. Philip Hammond (Runnymede and Weybridge): I draw the House's attention to my registered interests in respect of property, which are relevant to the context of clause 4, about which I have nothing to say this evening.
The Bill delivers the primary legislative changes that are required for the implementation of the national health service plan and the Government's response to the royal commission on long-term care of the elderly. The plan was presented to the House of Commons on 27 July last year. Perhaps surprisingly, given the apparent importance of the plan to the Government's strategy, this is the first opportunity that Parliament has had to debate it.
We have now waited six months to debate the 10-year plan to save the NHS, which was brought to us after three years in office by the party that was elected claiming that there were only 24 hours in which to save the NHS. It is hardly surprising that we read about the cynical interpretation of the plan by people such as the member of the British Medical Association's general practice committee who was quoted in the press as saying:
Our judgment and the judgment of the people of this country on the Government's management of our health service will be based on the state of the real NHS. The gap between the real NHS that people have to deal with every day of their lives and the virtual NHS that we increasingly hear about from Ministers at the Dispatch Box is widening as their ambitions expand. Dr. Hamish Meldrum, a BMA leader, said that
In those circumstances, it is perhaps no wonder that 84 per cent. of GPs surveyed in one of the GP publications described the NHS plan as "ill-resourced" and a "political tool". In a market research survey, 63 per cent. of the public believed that the plan was designed as a vote catcher and not a general commitment to reform.
In the Government's fantasy NHS, there is to be an end to automatic efficiency savings. In the real world, we read today that £1 billion must be slashed from catering and cleaning bills, while a third of our hospitals are officially described as filthy. In the Secretary of State's fantasy NHS,
In the Government's fantasy NHS, the Prime Minister apparently thinks that providing an hour a day of domiciliary care in a person's own home is the equivalent of creating an NHS bed, whereas in the real national health service the number of nursing and care home beds in many areas of the country is contracting at an alarming rate. I have no idea what the hon. Member for Wakefield (Mr. Hinchliffe) was going on about when he said that Conservative Members had been bleating about empty care homes. We have been bleating about the absence of any available care beds in many parts of the country.
I can give an example of the plan's detachment from reality. It establishes targets for GP services, such as a 48-hour guaranteed appointment, which we welcome, and it offers an extra 2,000 GPs by 2004 to achieve that target. However, when the Government were challenged by the entire medical profession with the evidence that it will take four or five times that number of GPs to deliver the plan, Ministers honestly admitted that the 2,000 figure had been included because that was the number they believed could be achieved. They did not remove those objectives from the plan, which they know cannot be delivered with the resources available. Apparently, the outbreak of honesty does not stretch that far in an election year.
The most important point to note is that, running through the NHS plan, through the Bill and through most of the Government's health legislation to date is a slightly sinister, unspoken but quite consistent theme of the desire, the need, for total control of the NHS--of every detail of every aspect of the service. Some of my colleagues might be inclined to be a little less charitable than me, but I have no doubt that the Secretary of State genuinely believes that taking more power to direct and micro-manage every aspect of the service for himself is the best, perhaps the only, way to improve the NHS. That is his instinct; it is in his blood, his upbringing. But history, experience and observation of the world, as well as a growing weight of informed commentary, are against him. We should not be squeamish.
The Secretary of State is running Britain's largest productive enterprise, the NHS, accounting for nearly 6 per cent. of the nation's GDP--a virtual monopoly producer of an important commodity, health care. To think that an organisation on this scale, operating in
The key to prosperity or even survival of an organisation on the scale of the NHS must be devolution, flexibility and diversity of response, but on the evidence of the Bill the Secretary of State still hankers after absolute power to micro-manage the empire. [Interruption.] There seems to be some dissent on the Government Benches. Let us look at the Bill. Remember, it is ultimate power that counts because that is the real power and the Secretary of State knows that very well.
The Bill contains clauses giving the Secretary of State the power to dictate the terms and conditions on which individual employees are hired and fired by every NHS body in the country. There are clauses to give him the power to dismiss boards or to hand over their functions to private contractors. There are clauses to force unwilling elected local authorities to surrender their responsibilities to unelected and as yet unproven care trusts. There are clauses that say that the Secretary of State can give or take money from any trust or primary care trust, bypassing health authorities and existing allocation mechanisms and their transparency and accountability. There are clauses that will allow him to grade NHS bodies through his traffic light scheme and dictate which of them have earned their autonomy by faithfully adhering to the line from Whitehall.
That degree of hands-on control or micro-management is not only dangerous but is bound to fail in an organisation of the size and complexity of the NHS. If the Secretary of State can point to a single successful productive enterprise on this scale anywhere in the western world, organised on a centralised basis, I would be pleased to hear about it because I have not been able to discover one.