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Lord Chan: I listened carefully to those who put forward the amendment and I was particularly taken with what they said about continuity and long-term planning. As I have already stated in this House, because the NHS has been in a process of continuing change over the past three or four decades due to edicts from Ministers, there has been no opportunity for those of us who work within the NHS to ensure that the changes deliver what they are supposed to deliver. Here I declare my interest, having been not only a clinician in paediatrics in the National Health Service but also on the board of a mental health trust and now in a primary care trust.

Therefore, the first important issue for those of us who work in the NHS is that we need time to ensure that the changes deliver what they should. However, I fear that that has not been the case because change has occurred so rapidly. Before one has time to assess what is happening, another change is imposed. Therefore, if a new agency, separate from government and politicians, observed long-term planning and continuity and allowed things to settle and to be assessed carefully, then—I say this on behalf of all of us who work within primary care trusts—I would certainly be in favour of it.

However, we believe that two issues are vital and fundamental to the success of the National Health Service. The first—what patients want in our community—is access to care, particularly from general practitioners. That has come about, certainly where I am based on the Wirral, through a decision, following discussion on the PCT board, which includes doctors, nurses and lay people, to change the appointments system completely. We said that the only appointments that should be accepted should be those which allowed the patient to be seen within 48 hours. We will not take any appointments beyond that time. As a result, 100 per cent of our patients are seen within 48 hours, and that change has taken place in only six months.

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However, because that has been so successful, we are now faced with another dilemma because patients say, "Ah, on the other hand, those of us with diabetes, high blood pressure and a whole lot of other conditions would like to have appointments in the general practitioners' register to be seen in three months' time". We are not sure how to solve that dilemma because at present the 48-hour appointments system is particularly good and places the onus on patients to remind the system when they want to be seen.

The second issue which is absolutely essential is that of co-operation and collaboration between primary and secondary care. At present, there appears to be too much competition between primary care and secondary or hospital care due to the questions of funding and, of course, control. Although it is true that the Government have increased funding by a large amount—up to 9 per cent a year—the issue for those of us who operate a primary care trust is that one-quarter of that money still sits in Whitehall in the Department of Health. In other words, we receive three-quarters of what is given to us, and that is certainly not a good measure. Therefore, if we had an agency at arm's length from politics, we would certainly hope that boards would be trusted by management to receive almost 100 per cent of the funds allocated to them.

Co-operation between primary care and secondary care can come about only if time is given for primary care boards and hospital boards to sit down and work out what is best for patients, particularly with local representation. At present, primary care trusts must pay the salaries of hospital consultants, and all our time seems to be taken up discussing the dispersal of money rather than deciding how to work better in order to improve the situation and care of our patients.

I hope I have not given the impression that professionals cannot decide how to behave professionally for the benefit of their patients. However, this type of difficulty arises when the system that we have is tinkered with every now and again by political expediency. Therefore, if those issues can be solved by an independent agency, we should certainly welcome that.

Lord Hunt of Kings Heath: First, I should declare a number of interests that are in the Register of Interests, but for the purpose of this debate I shall mention the King's Fund, Cumberlege Connections, KPMG and Beachcroft Wansbroughs.

This has been an excellent debate. I congratulate the noble Baroness, Lady Cumberlege, on allowing us to discuss once again the nature of the organisation of our National Health Service. The King's Fund has done an excellent job in producing its pamphlet. As one of those bungling amateurs, so beloved of the noble Lord, Lord Peyton, I have to hold up my hands and say that I agree with many of the criticisms that noble Lords have made about the way in which the Department of Health has traditionally approached

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the management of the health service. As the noble Lord, Lord Walton, suggested, I too would suggest that my own Government are not the only government who have been guilty of such a charge.

We can see that traditionally the NHS has suffered from being a political football; we have seen the impact of "targetitis", as it has been called, micromanagement and constant restructuring. I have indulged in, and thoroughly enjoyed, setting hundreds of targets, micromanagement and constant restructuring.

I have two things to say about that. First, it is clear that the Bevan structure, as opposed to the Bevan principles, is showing its age. Equally, in the rush to change the system that we have, we should be aware of simply saying that politicians should get out of the strategic direction of the NHS. Even some targets are justifiable. Without targets on waiting times, I believe that the health service would never have tackled the issue of cutting waiting times. I have worked in the health service for many years so I know that the NHS has never taken the issue of waiting times sufficiently seriously. Because of the very tough targets that have now been set we are at last seeing dramatic reductions in the amount of time that people have to wait for treatment.

Secondly, I am doubtful that the public corporation model is the right way to improve the way in which we manage the NHS from Whitehall. That has been looked at three times by government commissions of inquiry. First, there was the Guillebaud report in 1956; there was then the Royal Commission report in 1979; and most recently we have had Roy Griffiths's excellent general management report of 1983. The noble Baroness, Lady Cumberlege, quoted from Roy Griffiths's report, although she did not say that he considered the question of the NHS being run by a public corporation and he rejected that option. He said that the NHS is so important, so politically important, that it would be naive to think that a public corporation would ever be allowed to operate in the way in which noble Lords have suggested today.

I understand why people are critical of political involvement in the NHS, but without politicians the NHS would never have been created in the first place. Without the political process and the political accountability to Parliament I doubt that the NHS would now be enjoying the huge increase in resources that it has been given.

The noble Baroness, Lady Cumberlege, said that the agency would not be another quango, but reading the amendment it appears to be very like a quango to me. Far from creating the space that she desires from political involvement, it would simply replicate and duplicate what is already there. Yes, there would be a national agency, but the risk is that it would simply act in a way in which the department has acted over the past 50 years. What is the guarantee that such an agency would not micromanage, as the service has been micromanaged over the past two decades? In addition to such a national agency, there would still be the Department of Health, and Ministers would still be accountable to Parliament. I worry that such a

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national agency, far from creating the kind of freedom and space that the noble Baroness desires, would constrain the NHS even more than it is constrained today.

I also worry about the current trend to place as much of the work of government into independent agencies as possible. I have legislated to do that. But I worry that in doing so we undermine the democratic process. I agree with the noble Baroness that in terms of parliamentary accountability very few such agencies, if any, could be said to come under strong parliamentary scrutiny. For all the criticisms that can be made of the way in which we legislate and ask questions, the fact is that at the moment parliamentarians have the right to question and to scrutinise Ministers daily and they do.

The noble Lord, Lord Alderdice, said that he accepts that government will always be involved. The question is what is the best way for government to be involved. I agree with him. I believe that the structure of the Bill shows us the way forward because for the first time we now have national standards and we have an independent regulator. The room to give the NHS much more discretion has now been created. That is the importance of foundation trusts: locally owned organisations but in the NHS, operating according to national standards and subject to independent regulation.

4.15 p.m.

Lord Desai: Does my noble friend agree that foundation trusts have been emasculated in the course of the debate in the Commons precisely because there is too much central control? Had they been set up by an agency they would not have had that much interference.


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