Health and Social Care Bill

My Lords, could I try to cheer up the Committee? We are getting very gloomy about this topic. To me, this is one of the most important clauses in the Bill and we must support it. I hope that we can reassure colleagues on the opposition Benches that there is no intention, as far as I can see, to withdraw any accountability, which we have discussed at great length. Nor is there any intention to interfere with the ability of the Secretary of State to intervene when necessary. It is clearly written in the Bill that the Secretary of State has a mandate and a multi-year setting of objectives, but he has to stay clear of interfering until something is really at crisis point, is going wrong or is urgent. There is plenty of opportunity for him to interfere. I want to intervene because we have gone into the stratosphere with ideological and constitutional issues. We have certainly talked about political interference, and I agree wholeheartedly with the noble Baroness, Lady Cumberlege, about this. As a senior manager, I have a little list of Ministers around this Chamber who I can tell noble Lords did or did not interfere. I am delighted to say that the noble Baroness, Lady Cumberlege, was one of the least interfering of Ministers. Others around this Committee must wait for my judgment elsewhere. However, we are forgetting the impact of the status quo on patients and their care. For me, this is the most important clause because it underpins the move away from the strangulation of the management chain from the centre to every part of the service, down to the healthcare assistant, towards a devolved, regulated system. What is more—and this is, I have to say, very irritating—this has been the intention of all Governments for the past 20 years. It was very strongly pushed by the Opposition when they were the Labour Government, and reducing this micromanagement has remained a key policy. I will tell the noble Lord, Lord Mawhinney, what micromanagement is because I have often experienced it. Clause 4 is being called a hands-off clause but, as I have said, the mandate that is given over a multi-year period, with annually refreshed objectives, gives the Secretary of State a great deal of freedom to determine which policy objectives will be given priority. If the Secretary of State wants to interfere, he must come to Parliament to change that mandate and justify his reasons, but he can still do so. The key role of autonomy will be given teeth—not just the autonomy of the Secretary of State and various bodies such as the national Commissioning Board and the foundation trusts, but that of the clinical commissioning groups. This goes all the way down through the system. To be described as autonomous, an NHS body must be responsible for strategic management, procurement, financial management, human resource management and administration. By strategic management I refer to defining the overall mission of the service or hospital, setting the broad strategic goals, managing the service or hospital’s assets and bearing ultimate responsibility for the hospital’s operational policies. In the past few decades many countries have adopted various styles and degrees of autonomy, often giving autonomy to providers and to local purchasers and commissioners in public health systems. In countries as diverse as Thailand, New Zealand, Singapore and Spain, there have been a number of successful initiatives. In particular, I point to Catalonia, where, over the past 20 years, the public health system has been devolved to local commissioning organisations allied to the local authorities. This has freed providers from the predations of central government, which has had an enormously beneficial effect on the quality and efficiency of the public hospital system. Let us look at the UK and the imposition of what the central chain of command does. It manifests itself in performance targets. Targets are always popular—they are brilliant and, what is more, the NHS always meets them. It may take some time but, usually, if you tell the NHS to manage something and hit a target, eventually it will get there. In practice, a project board forms. Some hospitals have as many as 500 projects going on at the same time. That was the number that was found by one consulting agency. It found an enormous number projects under way to deliver these targets, often with external consultant help from the centre or the assistance of external consultants such as the big five. It can be demonstrated very easily that when a project is going on it is possible to reduce admissions, for example, by 60 per cent, with positive effects on cost, quality of outcomes, follow-up and discharges. It is possible to reduce the proportion of beds occupied by patients who are medically fit for discharge by 25 per cent to 30 per cent and so on.