Health Bill [Lords]

Thank you, Mr. Deputy Speaker. I must confess that I prefer dialogue to monologue, but we are under your direction. Let me at least make this point just one more time. What the Secretary of State said is simply not true. Patients who present with minor conditions and could be seen and treated are often not; they wait a long time. One Healthcare Commission report on emergency departments noted that that situation bears particularly on the elderly, who often wait almost four hours before they are discharged by the emergency department to avoid a breach. There is a range of such measures, and if, as he says, the proposal is already normal clinical practice, hospitals will have no difficulty building it into the structure of their performance measurement. The Secretary of State made an interesting point, however, because I remember that Kettering general hospital was one of the original pilots of the four-hour target. The hospital said that the target helped it to deliver change in order to expedite the treatment of patients. I said, "Fine. Do you think therefore that you should go from 95 per cent. to 98 per cent?" The hospital said no. I then asked whether it thought it should go from four hours to three hours. The hospital said no. Subsequent to my conversation with that hospital, which took place almost six years ago, the Government imposed the shift from 95 to 98 per cent., which the College of Emergency Medicine and many emergency medicine practitioners do not support. The Government did so in the belief that it was the right way to secure continuous improvement, but the right way to do so is to start performance management with the four-hour target and to move to an understanding that a range of quality metrics should be a part of the culture of continuous improvement. If it is not, we end up with 98 per cent. and four hours, and that is it. At Staffordshire general hospital and many others, it has become obvious that the focus on a single target for the delivery of emergency medicine leads to an immense range of distortions, many of which diminish the quality of care provided to patients. We talked briefly about the exceptions to the private income cap. The Secretary of State should not listen to the siren voices, who have now left the Chamber, on the Government Benches. If one were to abolish the option to provide private medicine alongside NHS medicine, one would cripple hospitals such as the Royal Marsden. If anybody wants to see how being able to offer private health care alongside NHS care is to the benefit of NHS patients, they should go to the Royal Marsden hospital, because, with the Healthcare Commission's ranking of double excellent year after year, it has demonstrated how it can reinvest the benefit of its private work in the NHS patients it looks after. The Opposition will be very critical if Ministers use a review as an excuse not to put into this Bill the opportunity for Ministers to introduce regulations to make exceptions to the private income cap. Ministers will know that Monitor feels that foundation trusts are highly constrained by the 2003 legislation. It can be changed only through this amending legislation; if it is not, the Government's review will take place at some point in the summer or autumn—after the primary legislation opportunity has disappeared. The Secretary of State talked about innovation, but, frankly, I am not sure whether we can give much credence to the way the Government have gone about innovation. The Darzi review, in an interim report in October 2007, said that there would be an innovation council. It met, but the Department's website says that it last met in April 2008. The council seems to have disappeared since then. The fund that was supposed to be set up with the Wellcome Trust on a 50:50 basis—£50 million each—seems to have just disappeared, too. The provision is in the legislation simply so that the Secretary of State can give money to people who have already done something. However, he already has the power to incentivise people to do things in the future; he does not need legislation to do so. I am sure that the hon. Member for Romsey (Sandra Gidley) will want to talk about pharmacy. The Government pursued dispensing doctors in an abortive attempt to remove some of their dispensing rights, and I worry that the Government are now seeing pharmaceutical needs assessment as a way, through primary care trusts, of arriving at a similar conclusion by a different route. We have to make sure that pharmaceutical needs assessments are real things that deliver real benefits, but the documentation that I have seen supporting such assessments simply says that primary care trusts should go away and work out what requirement there is for pharmacy services in their areas and commission according to that requirement. Where is the scope for patient choice, capacity building or a range of independent sector providers? Where is the freedom for pharmaceutical services to develop in response to need? We do not need primary care trusts to take to themselves more and more power over dispensing in their areas. I come now to what I think will prove to be the most contentious issue in the Bill: I am thinking of the Government's proposals on the point-of-sale display of tobacco. Time does not permit me to talk about the evidence at length, but I should say that my noble Friend Earl Howe and other Members of the House of Lords did a sterling job of considering the Bill and amending it in two important respects. They entrenched the constitutional principles of the NHS and put exceptions to the private income cap into the Bill. My noble Friend set out at length the difficulties with some of the research evidence that is prayed in aid by the Government on point-of-sale tobacco display. In truth, comparisons between Canadian provinces such as Saskatchewan, which went down the route of a display ban, and other Canadian provinces, which have not had a display ban but have taken some of the other measures, show that the latter provinces have made similar progress—sometimes even greater progress. I hope that we will have a substantial discussion in Committee on the subject. I hope that Government and Conservative Committee members will contrive to take evidence for that purpose, because our approach should be evidence-based and the evidence should be tested in Committee. When the Bill comes back here on Report, I hope that the Government, like us, will give Members a free vote. Hon. Members, including the right hon. Member for Rother Valley (Mr. Barron), the Chairman of the Health Committee, will well recall that, in itself, the giving of a free vote energised the debate about the ban on smoking in public places; in part, it led to the conclusion that we came to, rather than the one that would otherwise have been imposed by Ministers. I hope that, like us, the Labour party will give a free vote on these issues relating to public health and allow the evidence to determine Members' views on the subject. Although we will have a free vote, I should say that we on the Conservative health team strongly believe, like the Secretary of State, that smoking is still the greatest avoidable cause of premature mortality and that the rate of new smoking among young people is still far too high. We need to do whatever we can—if it is supported by the evidence—to ensure that as few young people as possible smoke. In that respect, we need to do more to combat smuggling and to act on nicotine replacement therapy, although those issues are not the subject of the Bill. We must ensure that the prescription and strength of NRT are optimised for the purposes of smoking cessation services. Furthermore, we want two measures that could be in the Bill to be looked at. The first is the banning of tobacco vending machines from public areas of licensed premises; at the very least, we should structure the legislation so that we can ensure that young people do not have access to these machines in such areas. Secondly, there is an anomaly between the proxy purchasing of tobacco and the proxy purchasing of other products, alcohol in particular. If adults buy alcohol for children, that is a criminal offence, but the same does not apply to the purchase of tobacco. We see absolutely no grounds for such a perverse anomaly; it is important that adults should not give young people alcohol, but it is probably even more important that they do not give them cigarettes. We will press for the ban on proxy purchasing to extend to tobacco. The Bill is a collection of measures that are not all bad; some are good. The incorporation of the principles of the NHS into legislation is a step forward, for which we have asked in the past. It has not been done precisely according to the NHS principles expressed in the NHS plan 2000; perhaps the Minister responding will explain why that is. Why has the principle that the NHS supports and values its staff been left out? That is rather curious. None the less, it is important that the principles are there. The Bill is a missed opportunity to create a real constitution for the NHS. Most of all, however, it is a missed opportunity to entrench the reform process in a way that would show that the Government are committed to a vision of a health care system that is at least as good as that of any other country in the world. The system's outcomes should be benchmarked against the outcomes of other countries' systems, not against a small number of narrow process targets that distort the activity of the NHS. We should create a framework that delivers reform and incentivises providers of NHS care to deliver a rise in productivity rather than the fall that we have seen in the past decade. We should see the delivery of real patient choice, with the information flows that make that happen. The Secretary of State said that there was a right to information in the constitution; actually, there is only a pledge that the NHS will strive to provide information—nowhere is it said that the information will be that which patients really need for choice to be supported. Furthermore, there is no evidence that Ministers want to create the kind of information revolution and marketplace for information in health care which would deliver the real empowerment of patients. We want a structure in which decisions are increasingly made at the front line, but the Government are still trying to have it both ways. They talk about devolution in health care, but they are actually entrenching a structure that is all about top-down command and control; it is still all about command and control at the Department of Health. Health Ministers' response to what I was saying about targets illustrated even more the fact that they cannot get their heads around the thought that their job is not to decide precisely what should happen to every patient who arrives at an emergency department. The issue is about those who are responsible for care. [Interruption.] The Secretary of State says from a sedentary position that he remembers what it was like. The change in capacity and the increase in resources are important, but it is to traduce NHS staff to suppose that if the Government did not impose a four-hour or 18-week target, NHS staff would say, "Oh well, patients can wait any amount of time—it doesn't really matter any more." NHS staff care more than any of us about the quality of care that they provide patients. If they have the resources, freedom, opportunity and an incentive structure that helps to make it happen, they will be potentially capable of delivering the best health care in the world. We know that the NHS is founded on the principle of equity, and we will not compromise on that principle; indeed, we need to do more to deliver it. However, in the past decade, under this Government, the NHS has become less efficient as productivity has fallen. It needs to become more efficient. Most of all, we must have excellence alongside equity. We will not achieve excellence in the NHS unless we focus on the outcomes and compare the health outcomes and health gain in this country with those of the very best health economies anywhere else in the world. I conclude with a motto: "Nil satis, nisi optimum." As the Secretary of State will know, it is the motto of Everton, his favourite football club. It means "Nothing but the best is good enough." That is our motto for the national health service; I hope that, in the Secretary of State's short tenure, it will also be his.