|Previous Section||Back to Table of Contents||Lords Hansard Home Page|
Baroness Hayman: My Lords, the experience of recent years, the Utting Report and the Government's response to it have shown that it is important that staff who have concerns about serious issues regarding the welfare and safety of children in their care should have the opportunity to raise them.
The noble Baroness will be aware also that in the White Paper on social services launched this week, we announced our plans to set up new independent commissions for care standards in every region of the country which in future will register and inspect all children's homes, whatever their size. Each one of those independent commissions will have a children's rights officer with a specific responsibility for safeguards in that area.
Baroness Hayman: My Lords, as I said in response to the noble Baroness, Lady Gardner of Parkes, we must look at the experience of staff who work in this field because, as the noble Baroness points out, they may have very challenging and difficult roles to fulfil. There is a proper balance to be struck between those who have had particular sorts of life experience and formal training needs. We shall look to the NTO--the training organisation for personal social services--to work with employers and others. We need to look at what is the right content and profile of the people we need to undertake that work.
If the top rate of tax was increased from 40 per cent. to 50 per cent. for taxable income over £150,000 a year then this would yield £1.5 billion at 1998-99 income levels and 80 thousand people would pay more tax.
Baroness Castle of Blackburn: Have I heard the Minister aright, that there are only 80,000 people in this country with a taxable income of £150,000 or more and 160,000 people with a taxable income of over £100,000? Does that not show how wealth in this country is accumulating in a few hands? Is it not true that the previous administration, under the chancellorship of the now Lord Lawson, in 1988 gave these people a great tax hand-out? Has not the DSS itself, in its recent statistics, pointed out that the gap between rich and poor in this country is continuing to widen even under this Government? Will not the Government therefore consider at least taking back some of the disastrous largesse which the previous government gave to those rich few?
Lord McIntosh of Haringey: My Lords, my noble friend has a valid statistical point. It is true that the figures for the number of people earning more than those thresholds has increased over the past year, although we believe that is much more because of
Lord Lawson of Blaby: My Lords, I apologise to the House for intervening a second time on a single Question time but the noble Baroness, Lady Castle, mentioned me. May I put another statistical fact into the pot which may be of some relevance to this issue? As a result of the reforms which I introduced as Chancellor in 1988, over the past 10 years, both the proportion of total income tax yield and the absolute amount paid by the top 10 per cent. of income earners has increased and not diminished.
Lord Razzall: My Lords, does not the noble Lord agree, without quite putting it in the same way as the noble Baroness, that, notwithstanding the Labour Party's pledge at the last election, were the amounts concerned to be raised in the way that the noble Baroness is suggesting, they would make a contribution towards fairness in our society and would make a contribution to the public expenditure aims which the noble Lord and I share?
Lord McIntosh of Haringey: My Lords, that is an entirely hypothetical question. Our commitment is very clear. The noble Lord can speculate as much as he likes. Over a drink, I might speculate with him. But it is not an issue of government policy.
Baroness Castle of Blackburn: Is it not a fact that the manifesto commitment to keep the Conservative taxing and spending plans related merely to the first two years of this Administration? Has it not been somehow magically extended in the minds of Ministers to avoid them embarrassment?
Lord McIntosh of Haringey: My Lords, with the greatest respect, I believe that my noble friend is confusing spending plans with income tax. We said that we should not change the previous government's spending plans for the first two years. As my noble friend knows, the comprehensive spending review announced this summer shows what significant changes are to be made in the following three years. But our commitment not to raise the basic or top rate of income tax was made explicitly for throughout this Parliament.
Lord Peston: My Lords, my noble friend used the expression "statistical point". Perhaps I may ask him to clarify another statistical matter. I take it that he is referring to what one might call income tax units as declared to the Inland Revenue in this country. Therefore, to revert to one of our favourite topics this
Lord McIntosh of Haringey: My Lords, the figures which I gave are based on an excellent survey of tax returns as submitted in this country and only in this country. They are based on 75,000 tax returns. It is a one in 10 sample of incomes over £100,000 and an even bigger sampling fraction of the very largest incomes. The figures are highly reliable for tax returns made in this country. They do not apply outside.
Lord Carter: My Lords, at a convenient moment after 3.30 p.m., my noble friend Lady Farrington of Ribbleton will, with the leave of the House, repeat a Statement being made in another place on the local government finance settlement.
The Lord Chancellor (Lord Irvine of Lairg): My Lords, I beg to introduce a Bill to establish the legal services commission, the community legal service and the criminal defence service; to amend the law of legal aid in Scotland; to make further provision about legal services; to make provision about appeals including cases stated and applications for habeas corpus and the reporting of court proceedings; to amend the law about magistrates and magistrates' courts; and to make provision about immunity from action and costs and indemnities for certain officials exercising judicial functions. I beg to move that this Bill be now read a first time.
In my opening remarks, I intend to focus on health issues and my noble friend Lord Williams will deal in more detail with home affairs when he closes the debate. The whole House will look forward to the maiden speech of my noble friend Lord Warner from whose wide experience in these fields I am sure we all have much to learn.
This summer we celebrated the first 50 years of the National Health Service. Its enormous achievements are acknowledged. But today it faces formidable challenges: advances in medical technology, changes in demography, work patterns and family life and growing public expectations. Our pride in the achievements of the past 50 years should not make us wish to stand still but rather should reinforce our determination to ensure that the necessary changes take place to ensure the equal success of the National Health Service in the next century as it has enjoyed in this.
It is now one year since the Government published their plans to replace the internal market and rebuild the health service. Substantial progress has already been made to implement those plans and the NHS Bill will build on that work.
The plans begin a 10-year programme that the Government have now backed with the biggest cash injection that the NHS has seen in 50 years, amounting to an average real terms growth of 4.7 per cent. for the next three years. That is investment for lasting success which will bring demonstrable improvements year on year.
We have made good progress across the board in implementing our plans to build a modern and dependable NHS; for example, in developing the new primary care groups. Their establishment is not dependent on new primary legislation. There are 481 groups already in place and they will become live from April 1999.
Primary care groups are borne out of the experiences of what general practitioners, nurses and managers have been doing over the past few years, despite the obstacles provided by the internal market. Their three key functions are to improve health, commission high quality care by developing long-term service agreements with trusts, and develop high quality primary care services. Primary care groups will cut bureaucracy by abolishing thousands of commissioning and fundholding groups. They will put local doctors and nurses in the driving seat in delivering services.
The NHS Bill will end GP fundholding. It will also take the primary care group model further. Primary care groups who want to be independent and are capable of being so will be able to apply for primary care trust status. Those trusts will allow for the integration of community and primary care services in a way never possible before--they will shatter the old boundaries between services.
Raising standards in the quality of NHS care is at the heart of the Government's drive to modernise the NHS. Our proposals are set out in the consultation document A First Class Service, published in July, and have been warmly supported.
All patients who are treated by the NHS want to know that that they can rely on receiving high quality, safe and effective care when they need it. And, overwhelmingly, they do receive it. But as we have all seen, when things go wrong the consequences can be appalling.
The NHS Bill will place a duty of quality on NHS trusts and PCTs to support clinical governance. It will also establish a new external body, the Commission for Health Improvement, to tackle organisational failures as well as ensuring that a system of clinical governance develops in a way that will prevent many of today's problems from repeating themselves in the future.
The Bill will also include measures to strengthen existing systems of self-regulation of the healthcare professions by ensuring that they are more open, responsive and publicly accountable. The Government are discussing the detail of the measures with the professions. Perhaps I may make it clear right now that we will work with the professions not against them, to ensure that the protection of the public is at the forefront of changes to the law. The professions cannot provide effective self-regulation without continued responsibility for the register; the standards of education for entry to the professions; guidance on standards of conduct and professional performance, and for the fitness to practice procedures.
The Government are committed to renegotiate the Pharmaceutical Price Regulation Scheme with the pharmaceutical industry and are currently conducting negotiations with representatives of the industry. The Government regret that there is increasing non-compliance with the voluntary agreement. The Bill will contain powers to ensure compliance with the new agreement when reached. Those powers will not affect those companies committed to complying with the PPRS but are necessary to secure compliance from other companies that might choose not to abide by it.
Partnership is key to the Government's plans for modern health and social services. Instead of the fragmentation and bureaucracy of the internal market, the Government are building a system of integrated care, based on partnership. Services should be built around the needs of those who use them, but all too often the traditional boundaries that exist between services can be a major obstacle to this. In the discussion document Partnership in Action, we set out our plans to make partnership a reality by removing barriers in the existing system and introducing new incentives for joint working. Those plans go with the grain of what the NHS and local authorities are seeking to achieve. They have been warmly received.
The Bill will include a substantial package of measures to promote partnership. It will place a new duty on NHS bodies to co-operate with one another and with local authorities. Development of the first health improvement programmes is on track and these will be
We are committed to create modern and dependable social services. On Monday, my right honourable friend the Secretary of State for Health outlined proposals in another place to ensure that we have social services which are convenient to use, can respond quickly to emergencies and provide top quality services for those who need them. Those proposals reflect the priorities within the local government Bill--to which my noble friend Lord Whitty alluded on Monday--so that a duty of best value on local authorities will secure continuous improvement in the delivery of services.
The White Paper, Modernising Social Services, proposes to lay down new standards of delivery and performance, so that people who need help from social services are treated with dignity and provided with what they need in a way which promotes rather than diminishes their independence. As a result of the comprehensive spending review, £1.3 billion will be made available over the next three years to support the modernisation which is necessary to take those changes forward.
This Government are committed to attack the root causes of ill health, improving lives and saving the NHS money in the process. Early next year we will publish a public health White Paper developing the proposals contained in the Green Paper Our Healthier Nation, which we published in February. Those proposals will be informed by the results of the independent inquiry into inequalities in health, which published its findings last week.
Smoking is the leading cause of preventable illness and premature death in the UK today. The Government plan to publish a White Paper before the House rises for the Christmas Recess. The proposals will announce how we intend to implement the EC directive on tobacco advertising to deliver our manifesto commitment to ban such advertising. The White Paper will set out a package of measures designed to reduce smoking--a key component in achieving our wider public health goals.
A short Bill will be introduced with the intention of helping hospitals in England, Scotland and Wales better recover the costs of treating the victims of road traffic accidents. The present system can trace its origins back to the 1930s, pre-dating the National Health Service. Under the current scheme when a patient, who has received treatment following a traffic accident, makes a successful claim for personal injury compensation against the holder of a motor vehicle insurance policy, then hospitals have the right to seek payment of part of the costs of treating the victim from the compensator's motor vehicle insurance policy.
Although hospitals currently have the right to seek payments, problems arise because there is no agreed administrative procedure for undertaking the recovery of those charges. The results, not surprisingly, are patchy. We estimate that the NHS undercollects the amount which is due by a very large margin.
The Road Traffic (NHS Charges) Bill will introduce centralised collection of NHS charges by using the system already established for the recovery of state benefits from compensation payments. That will relieve hospitals of the administrative burden, while at the same time giving the insurance industry a single point of contact and an administrative system already familiar to them.
Turning to home affairs, the Immigration and Asylum Bill will implement key elements of the comprehensive strategy for reform set out in the recent White Paper. For far too long, changes in immigration legislation and policies have been made in a piecemeal fashion. The result is a system which is slow and outdated and in which huge backlogs have been allowed to develop. This is unfair to genuine applicants and encourages others to exploit the system. The Bill is vital to deliver the fairer, faster and firmer system to which the Government are committed.
The Government made a manifesto commitment to bring forward a Freedom of Information Act, which will lead to more open government and form a key part of our constitutional reform programme. A draft Bill will be published early next year for public consultation and for scrutiny by the House of Commons Select Committee on Public Administration.
The Government will also bring forward a Youth Justice and Criminal Evidence Bill to create a new form of sentencing for young offenders and to provide measures to protect vulnerable or intimidated witnesses when giving evidence in criminal trials.
We shall also introduce a Bill to provide a free vote to equalise the age of consent, and to provide provisions to protect children from abuse from those in a position of trust. In response to concern expressed in both Houses during the previous Session, the Bill will also provide a limited criminal offence to protect young people when they are particularly vulnerable or the position of trust particularly strong, for example in education or residential care.
The Government strongly welcomed the fifth report of the Committee on Standards in Public Life, chaired by the noble Lord, Lord Neill, on the funding of political parties. The report provides a valuable framework for implementing the Government's manifesto pledges to require disclosure of large donations and to ban foreign funding of political parties.
The European Parliamentary Elections Bill is familiar to Members of your Lordships' House. It provides for elections to the European Parliament to be conducted using the simple regional list system. Great Britain will be divided into nine large regions, each returning
As I said at the introduction of this speech, the Government are committed to renewing and modernising the NHS and social services and to bring in this process with the investment necessary for reform. The measures identified, along with the measures we shall take on home affairs, will help us to make considerable progress this Session in delivering our specific manifesto pledges relating to health, but also to the Government's wider agenda to modernise and renew our National Health Service.
Earl Howe: My Lords, I should like to begin by expressing my appreciation to the Government and the usual channels for allowing time for a fifth day of debate on the gracious Speech and for giving the House, in the process, the opportunity to direct its attention to issues relating to health and home affairs.
While there are obvious areas of convergence between those two subjects, one cannot pretend that the potential field of interest is not a wide one. Looking at the list of speakers--including, I am pleased to say, the noble Lord, Lord Warner--I have little doubt that today's debate will reflect that fact. The noble Lord, Lord Williams, to whose lot it has fallen to sum-up all five days of the debate, has my good wishes and a measure of sympathy, although not too much of the latter.
By contrast, on this Front Bench matters are delightfully clear cut. My own contribution will be devoted exclusively to health issues. My noble friend Lord Henley, who will wind-up the debate from these Benches, will concentrate on home affairs. I shall not anticipate his remarks but I should like to assure the noble Lord, Lord Williams, that we await with interest the three Bills promised from his department: that is, the asylum Bill, the age of consent Bill, and the Bill relating to criminal justice. As always we will, in this House, give those Bills the thorough examination they warrant. I dare say that some will prove more controversial than others.
The Government's reform of the health service was heralded a year ago in the White Paper, The New NHS. At the time of the original announcement I remember describing the proposals--in so far as I then understood them--as being bold. But I think that everybody recognised, perhaps not least the Government, that much needed to be done to flesh out the proposals and prepare the ground for their implementation within the health
I have always said that we, from these Benches, have no antipathy to change in the health service. Indeed, we stand ready to support and encourage the Government in introducing new ideas which will work to the benefit of patients and make the NHS more efficient. So I start from a base of wanting to be positive about the Government's plans. The noble Baroness the Leader of the House referred in her speech to,
I want to focus my remarks today almost entirely on primary care. As the Minister explained, the Government's intention is to bring to an end the system of GP fundholding and in its place establish a structure of GP collectives or primary care groups. The Government's main criticisms of fundholding, if I am not misrepresenting them, are twofold: that it is bureaucratic and administratively costly; and that it has created a two-tier system of patient care. Those propositions merit close examination in their own right, but to assess the way fundholding is actually working it is surely right to look at it in the round.
The rationale for fundholding, when the previous Government introduced it in 1991, was to give GPs greater financial and clinical autonomy, and in so doing deliver a better standard of care to patients. Today, I do not think there is much dispute that that approach has been vindicated. Fundholding has enabled GPs to secure shorter waiting times for their patients' operations; to develop new specialist services; to develop surgical procedures within the practice itself, so avoiding the need for hospital visits; and to improve surgeries and waiting rooms.
The issue, therefore, is whether those manifest advantages are outweighed by the perceived disadvantages--bureaucracy and two-tierism. A great deal of academic time and effort has been devoted to securing answers to that question. I cannot hope to traverse the entire scope of such work--even if I knew it!--but it is perhaps interesting to look at the views of one particular authority, Professor Howard Glennerster, who was, incidentally, at one time an advisor to the Labour Party. The professor has examined the extent of the bureaucracy in fundholding and, not surprisingly, he has found that there are indeed management costs associated with it. But his conclusion was that any extra administrative costs are outweighed by the efficiency improvements which the system produces. In simple terms, he is talking about value for money. That is why I believe it is quite wrong, as the Government now seem to be doing, to point an accusing finger at the administrative costs of fundholding and completely ignore what it achieves in the round.
The other criticism of fundholding--that it has created an unfair, two-tier system in primary care--is, I think, rather a strange one. It amounts to saying, "Never mind the 60 per cent. or so of patients who are reaping the benefits of fundholding; there are the 40 per cent. who are still looked after by non-fundholders, and for their sake the only thing to do is to sweep away the entire system". I might be able to warm to that argument, illogical though it is, if the prospect on offer as an alternative to fundholding amounted to a general levelling up of standards as opposed to a levelling down. I should like to spend a few moments looking at primary care groups, or PCGs, to see whether they seem likely to pass that test.
Primary care groups, to remind your Lordships, will consist of groups of 50 to 100 GPs in pre-defined regions, supported by nurses, social service professionals and others, including lay representatives, who will be able to commission health services for their patients from hospitals. Unlike fundholding, the system will not be voluntary and PCGs will, therefore, cover the whole country and all patients. When primary care groups were first announced last year there were those who thought that they amounted to a sort of "fundholding writ large". That is a misconception. The first difference is that a GP will no longer be able to act individually for his patient in commissioning hospital services, as in fundholding. He can only take action as a member of a PCG, in conformity with the arrangements laid down by the PCG management board and the health authority. Noble Lords may think that this is not a very significant point. But, in practice, PCGs will not have a meaningful choice when it comes to the selection of trusts to commission services for their patients. They will be locked into long-term service agreements with local hospital trusts, which will virtually dictate where referrals are to go.
The other important feature of PCGs is the way in which resources will be allocated. At the moment, a fundholder has every incentive for efficiency, because efficiency savings can be ploughed back into more and better services for patients. But in a PCG a doctor will have almost no incentive to generate savings at a practice level, because any efficiency gains will simply be swallowed up by the whole group. Not only is that a retrograde step in itself; it also gives rise to the problem of the free rider. If one practice within the group is inefficient, then the entire group will suffer the financial consequences.
All this will serve to do several things. Practices will no longer have the flexibility they now have to be innovative and to refer patients to a wide choice of hospitals and consultants. They will be less efficient. They will much less easily be able to,
There is another aspect of primary care groups which resonates, I have to say, with a particular irony. The Department of Health envisages a four-point scale of PCG responsibilities. The first point in the scale, at the basic level, is a PCG which is merely an advisory body to the health authority. It would have no devolved responsibilities and no decision-making ability. The next point upwards would be a PCG which would have a devolved responsibility for managing the budget, but only as a part of the health authority, which would retain overall control. The third level of PCG would be one with structural independence from the health authority, but which would still be accountable to it for everything it did. The fourth, fully adult version of the PCG is the primary care trust--independent, and able to commission or provide community health services for patients.
So there will be four possible levels of PCG. Each successive level will have a progressively greater ability to manage its own affairs. I believe that if the experience of fundholding has demonstrated anything, it is something very simple: namely, the greater the autonomy of a GP, the better the patient care. It seems to me to follow from that those PCGs which are merely advisory bodies to health authorities will not be able to provide levels of service that are equivalent to the more advanced and autonomous PCGs. Certainly, PCGs can aspire to climb up the ladder of seniority over time, but the practical result of the structure that I have described will be a patchwork quilt of primary care groups, in four colours--if you like--spread over the country with an unequal distribution of colours. You as a patient, living in a particular area, will have no choice but to register with the PCG covering your home area. Never mind if in the next village there is a practice belonging to another PCG which you like the look of rather better. If
In brief, the measures that we shall be asked to consider are not really about building on the best of what we have at the moment. They are, I fear, about a levelling down of standards; an erosion of choice; and a curb on efficiency. That is quite a heavy price to pay for some of the features of PCGs which, in fairness to the Government, do represent a step forward: the closer involvement of nurses in commissioning health services, for example; and the promise of greater integration between healthcare and social services.
If I express this fear about the quality of care differing by postcode and choice being eroded, I am simultaneously conscious of not having done the question full justice. The whole issue of clinical governance is unfortunately too huge for me to cover today, and must wait for another occasion. But there are features of the Government's proposals in that area which suggest a very much greater element of control on GPs exercised from the centre than anything we have seen hitherto. The treatment guidelines from the National Institute for Clinical Excellence will need to be enforced with a very light touch if they are not to erode a doctor's freedom to decide what treatment is in the best interests of his or her patient--a freedom threatened in any event by the arrival of something else that is new; namely, cash-limited prescription budgets. These are the reasons why the other much talked-about justification for PCGs--that they will facilitate better strategic planning in the delivery of healthcare--has, to me, more than a ring of newspeak about it.
Unfortunately, these are not the only problems. Primary care groups will command enormous budgets which will need managing. Who will manage them? At the moment the answer seems to be that it will be the GPs and nurses themselves who will be in charge of this money. Are they adequately trained to do this? I should like to ask the Minister what the total cost of that management input is likely to be. Can he confirm that the figure calculated by both the King's Fund and Professor Alan Maynard of York University that the administrative cost of PCGs will be about £150 million per year? Perhaps I may suggest to the noble Lord that that is rather more than the current cost of running fundholder practices. We hear a lot about the need to reduce bureaucracy in the NHS, but what seems to be happening at the moment is the worst of all possible worlds: large numbers of professional managers being made redundant, at considerable cost, in anticipation of the changes to come; and the prospect of doctors, many untrained for the task, being paid a fee to manage PCGs. Every day that a GP spends round a board table is a day spent away from his patients. At a time when there is a nationwide shortage of GPs, primary care groups will
The future shape of primary care in Britain is a sine qua non for a successful NHS. The Bill, when it comes before us, will reveal whether and to what extent we can be confident of that success. From these Benches, we shall wish to ensure that, for the Government to carry the day, they will do so on the merits of their arguments.
Back to Table of Contents
Lords Hansard Home Page