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5.57 pm

Tony Wright (Cannock Chase): When I was listening with great interest to my right hon. Friend the Member for Livingston (Mr. Cook), I remembered hearing him say many years ago—when he was our party's health spokesman—that he would be applauded at meetings even before he spoke because everyone knew that ours was the party of the NHS. Of course, that was an enormous political asset for us, but at the same time it was an enormous political and intellectual disability. It meant that for a long time we did not really need to think seriously about the organisation of the health service,

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because it was our service. There were no political dividends in fiddling about with it. The resulting problem was, of course, that over the years we accepted a performance from the NHS that we should not have accepted. It had become unsatisfactory, yet we kept defending it and telling people how much we loved the principles embodied in it. Well, we do love those principles, and we want to preserve them and build on them, but that must not lead us always to be the defender of the conservative option that says that we must not alter the way in which the NHS is organised.

I was very conscious of a particular comment by one of my colleagues, and it is certainly true that the most telling moment during my brief look at the Health Committee's report was when I noticed the table illustrating that organisational change has taken place inside the health service in each of the past 20 years. I have to ask myself—as everyone else doubtless does—whether I would like to be a manager in the NHS, faced with that context. I would not, of course, because I would spend a lot of my time dealing with that change.

If we set such things to one side of the argument, it is tempting to say—some of my hon. Friends have got close to this—that we are now putting in the money, the capacity is increasing and therefore all will be well. If I thought that that was the truth, I would say that we should not touch further reform, as it would be much simpler all round to take a steady-as-she-goes course. I do not think that that is the case. I just do not think that we can run the service from the centre any more. We need a bold move towards local self-government in the health service. Ironically, we need that alongside a planning system. Those are not alternatives.

I have listened to today's debate, and it will be almost incomprehensible to the people whom we represent. They will have no idea what we are talking about most of the time. They have no idea who runs the health service. All they know is that the Government are responsible for it, and it is the Government whom they will hold to account—indeed, the Government have said that. But most people have no clue whatever who is responsible for their local services. They do not comprehend all the stuff about trusts and PCTs, and so on.

My right hon. Friend the Secretary of State says that the power lies with the PCTs. Well, of course, it does in our commissioning model, but, as has been said, that is not the bit that we intend to democratise. We intend to democratise provider units, which is a bizarre way to proceed. I am not sure whether we need to do that, even though we want to develop some kind of local self-management, so there is a difficulty. When people ask, "Who is accountable for what goes on in the health service?", they have no answer at the moment, apart from its being the Government. I am not sure whether they would have a more intelligible answer under the proposed system. That is a real worry.

I have only one further observation to make. I said that I remembered what my right hon. Friend the Member for Livingston said some years ago; I remembered something else, too. During the days of the Conservative Government, someone came along to an advice surgery one Friday evening with a complaint about the health service and put a copy of the patients charter on the table. We had trouble with the citizens charter. We used to say on one hand that we had

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invented it and, on the other, that it was a cosmetic irrelevance—what we said depended on which audience we were talking to. I was struck by the fact that that person believed that people had acquired certain rights in relation to the health service. I hope that we can explore that avenue further, and we are beginning to do so now. We now tell people, "If you don't get your heart surgery within six months, you can go elsewhere and we'll pay for it."

We can argue whether the state is good at running things, but it is very good at raising money to run things. I want to move far more towards a system—it is inevitable in the world that we now live in—where people say, "We are putting vast sums of our money compulsorily into the NHS. We don't want to know just what you're going to do managerially to the NHS or which latest reorganisation you're going to engage in. We want to know precisely what we will get for our money." If we cannot answer that question by giving people some serious public service guarantees, we can talk all we like about managerial changes, but it will not add up to much on the ground.

6.4 pm

Dr. Phyllis Starkey (Milton Keynes, South-West): Before I talk about foundation trusts, I want to put the Bill in context. The Labour Government's first election in 1997 and, even more so, their re-election in 2001 were primarily about people's desire for high-quality public services, paid for by taxation. The deterioration in the NHS under the Conservative Administration and the failure of the attempts by the Conservatives, then and subsequently, to encourage people to buy their way out of a deteriorating service through private health insurance were among the reasons that voters switched in large part to Labour in 1997 and 2001. People realised how expensive a private health care system would be, and voted instead for the principles of the NHS: a comprehensive health service, largely free at the point of use and available according to clinical need, not the ability to pay.

Since 1997, as we all know from our constituencies, the Labour Government have invested heavily in the NHS, and we have all seen the advantages—extra nurses, doctors and physiotherapists, new or improved hospitals and primary care buildings, and extra GPs. Although that extra funding is essential for an improved NHS, it is not sufficient. Alongside the extra money, we need modernisation and a way of reworking the NHS to enable it to respond more appropriately to current conditions and make the maximum use of resources.

My hon. Friend the Member for Cannock Chase (Tony Wright) said that the public were not interested in managerial matters. I agree absolutely; they are interested in outputs. I am now, however, going to talk about managerial changes, because those changes are necessary to enable us to deliver the outputs on which the public will judge us.

Innovation within the NHS has already been extremely effective in making the additional resources go further and in providing services that are more appropriate. That innovation has involved introducing different ways of working between social services and the NHS, redistributing tasks to make better use of nurses and nurse consultants, implementing better

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co-operation between primary care and the hospital sector so as to move out of hospitals those cases that are more appropriately dealt with in primary care, and, in particular, managing more effectively people with chronic illnesses such as diabetes, who need the acute sector and the community sector to work more effectively together.

Such innovation can be very speedy. Some Conservative Members—not the two who are present at the moment—have cited an example that, they say, illustrates a response to a central diktat: namely, the way in which many GPs have introduced a system under which patients cannot book an appointment for further than 48 hours ahead. In fact, that system was not adopted because of a central diktat. Some GPs tried it out as a way of providing a better service for patients who would otherwise find it impossible to get an appointment within seven or eight days. They found that the system worked, and other GPs copied it.

That is an excellent example of innovation being picked up and spread through the NHS when it works, but innovation works best when the staff who work in an institution, be it a hospital or a PCT, make the change themselves because they want to, rather than being told from above that a change must be made. Clinicians particularly resent being instructed, but, faced with a problem that affects their own patients, they have every incentive to come up with a solution. I repeat: people change most easily when they want to, not when they are made to.

That is where foundation trusts come in. They will give local hospitals, and subsequently PCTs, the freedom to innovate without being slowed down by the need to get agreement through the multiple layers of NHS bureaucracy. I make no apology for quoting the much-cited Professor David Kerr, who seems to write particularly good letters. In a letter to me, he wrote:

Foundation trusts are an especially good way of ensuring that such innovation occurs and that, when it does occur, they may be a beacon for the rest of the NHS and encourage others to follow the innovation.

Some of the opponents of foundation trusts have alleged that they would create a two-tier NHS. Many people, and the report by the Select Committee on Health, have pointed out that we do not have a two-tier NHS because we have always had, despite our and previous Governments' best endeavours, a multi-tier NHS. All of us know of hospitals that provide an excellent service and of others that provide a much poorer service, which is not because they receive less funding than better hospitals but because of poor management, bad staff morale and even personality clashes among staff that stop co-operative working.

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People who work in the NHS know which hospitals have a good atmosphere and which are plagued by problems, and those problems cause staff to be poached from one hospital by another. They move to hospitals in which they know their work will be appreciated and have a good effect, and away from hospitals in which enormous quantities of energy are wasted because of bitching and inter-rivalry.

We need to create an environment in which trusts are free to innovate and copy the best practice of others. The NHS bureaucracy must concentrate on helping trusts with problems and bringing them up to the standard required. It is absolute madness for people to suggest that the NHS should continue to micro-manage all trusts regardless of whether they need it, but equally it is not sensible to give greater freedom to trusts that do not make the best use of their human and financial resources.

The Government have put in place a strong framework of inspections and standards, including such measures as national service frameworks and targets for waiting times. The framework will apply to all trusts—foundation trusts or otherwise—and will ensure that there are overall standards. It sometimes appears that opponents of foundation trusts want to stop some hospitals being better than the current standard only because every hospital cannot be better at once. There was a lot of talk earlier about dogs eating dogs. That epitomises a dog in the manger attitude—

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