Health Bill [Lords]

Yes, my right hon. Friend is quite right about that. Let us take one example: where in the constitution, if rights to treatment are so important, is the right of access to NHS dentistry? It does not exist. The Secretary of State says that there is a right of access to NHS treatments as recommended by the National Institute for Health and Clinical Excellence, but that is only precisely the same legislative provision that was put into a statutory instrument years ago, and it is a right that all our constituents have had breached time and again. There is nothing new whatever in the constitution that changes that statutory provision. If one wants a constitution, it has to do what constitutions do: define the duties, responsibilities and accountabilities of the organisations within the NHS. I am afraid that that opportunity has not been taken in the Bill. In that sense, it is a clear wasted opportunity. We know that we will need to restore to patients the clear voice that was abolished when the community health councils were abolished, that was further undermined under patients forums, and that has not been restored under local involvement networks, or LINks, especially at a national level. We will have to create the mechanisms by which commissioners and providers can be properly separated, because the legislation to do it is simply not there. We know that primary care trusts in parts of the country are trying to create a separation between their commissioning activities and their provider activities, but legislation prevents them from doing so. Have the Government created an opportunity in the Bill for that important constitutional change to be made? No, they have not. Have they put back into legislation what they took out in 1999—the opportunity for general practitioners on the front line to be able to exercise real commissioning responsibilities? No, they have not. They leave that with primary care trusts. I am afraid that the Government's approach in the Bill has not been to take the opportunity to entrench in constitutional form the kind of accountabilities and responsibilities that would go with the reform process that the NHS is really looking for. The new Secretary of State must remember his former boss, Tony Blair, making a speech about the character of what was required for reform in the national health service, because he became a Minister in the Department of Health at almost the same moment. If I recall correctly, that speech was made in June 2006, just when the Secretary of State took up his post as Minister. It was probably part of his instructions from No. 10 to go in and try to push the reform process. I think that was part of his responsibilities as a Minister. It was about accelerating patient choice, extending practice-based commissioning, completing the transfer of NHS trusts to foundation trusts, and stimulating additional capacity for the NHS through the independent sector. Those were the four drivers of reform that Tony Blair talked about. What has happened? All four have stalled. The last Secretary of State did not deliver on patient choice. It went up by just 3 per cent. Only 3 per cent. more patients believed that they had patient choice. Most of the time, less than 50 per cent. of patients felt that they had choice when they were offered elective operations. The Audit Commission has demonstrated that practice-based commissioning has stalled. I talk to GPs across the country who say that it is not happening. The primary care trusts, in effect, feel that they have been told by the Department of Health that they can take complete control of commissioning again and close GPs out of it. The NHS trusts were all supposed to have become foundation trusts by December 2008, but they are coming through only one at a time. The independent sector has been dissuaded from additional investment because the recently departed Secretary of State told them that, as far as he was concerned, the issue was one of capacity, not of competition. The Government believed that in many parts of the country they had sufficient capacity in the hospital sector and therefore that they did not need the independent sector any more. They feel that they can turn the independent sector on and off like a tap. The reform processes for which the new Secretary of State used to be responsible have all stalled. The Bill does nothing to drive any of them forward or to provide the drive, the pace and the institutional architecture that would help to entrench the reform process for the longer term. I turn to what is in the Bill, as opposed to what should be but is not in it. On direct payments, if the new Secretary of State and I are debating who was in favour and who was not in favour of parts of the Bill, he will concede that in January 2006 the then Health Secretary, the right hon. Member for Leicester, West (Ms Hewitt), flatly rejected the possibility of extending direct payments from social care to embrace aspects of health care, which we were arguing for at the time. She said that that was inconsistent with the NHS principles and that it was revisiting the patient's passport. The right hon. Gentleman says that as a Minister he considered direct payments—but presumably turned down the idea—so he was no doubt embracing that thought. I am glad that there has been a change of view on his part and that of the Government. We will support the proposal, but we must make sure that it is done well—not only cautiously, but well—and that the institutions in the health service that are charged with it do not try to frustrate it. I am seriously worried that, in their commissioning of NHS continuing care and some of the joint purchasing of social care, PCTs are going through purchasing structures like reverse e-auctions, the effect of which is to deny those who enjoy personal budgets the possibility of using them in ways that are flexible and responsive to their needs, rather than precisely as predetermined by the primary care trust. On quality accounts, the Secretary of State knows that we share the view that quality needs to drive the activities of the national health service, but we must be aware, as must the right hon. Gentleman, that too often commissioning in the NHS has been on the basis of cost and volume not quality. After his predecessor's unhappy experiences in the case of the Healthcare Commission's reports on Maidstone and Tunbridge Wells and on the Mid Staffordshire Foundation Trust, it is clear that in both cases the primary care trust was pursuing an approach of commissioning for cost and volume, not for quality. Quality is very important. It is difficult to be sure that quality accounts will, of themselves, deliver such quality. Let us take an example. In the case of the Mid Staffordshire Foundation Trust, we know that many organisations, including the Department of Health, treated compliance with a four-hour target as a measure of quality in the handling of admissions to the emergency department at Stafford general hospital. The Department and its fellow organisations, such as Monitor, published a document to tell us what quality accounts might look like. It is helpfully entitled, "The Sunnyview University Hospital Trust". I have a copy. In the Department's lexicon of communications, if something is called the Sunnyview document, everybody will no doubt treat it as an optimistic document. Unfortunately, when one looks at the document to see what quality accounts on emergency care would mean, one sees that it focuses on targets. It says that the measure of quality is adherence to the four-hour target, but we know that that target is only one measure, and an insufficient measure in the experience of the Stafford general hospital, because the staff there said that in order to meet that measure, they had to compromise the quality of patient care—not support quality or deliver that care, but compromise it.