Health Policy InsightEditorial Tuesday 11 October 2011: Lords debate Day One, with bravura Bottomley and crusading Crisp
The House of Lords Health Bill debate streaming can be seen here.
The debate has been of mixed quality, with perhaps the outstanding speech from Lord Owen.
......................................................................
......................................................................
Earl Howe made a courteous exposition of the Government's case, although it was slightly hindered by the circulation of this letter to peers, much-referenced in the debate.
Earl Howe said, "Doing nothing is not an option in the NHS ... this is the inverse of a top-down reorganisation ... Liberating the NHS means freeing FTs from the private patient income cap ... for the benefit of NHS patients".
Ahem.
He also promised "a careful transition process on education and training", but did not outline what it is.
It's a day for letters: Andrew Lansley (saviour, liberator) sent constitutional expert Lord Hennessy this letter, after his appearance on the Today programme this morning. Lord Hennessy is the co-author with Lord Owen of the amendment to send aspects of the Bill back into committee.
Following meetings with Earl Howe, Owen and Hennessy were unable to offer guarantees on deadlines for discussions - but did reduce the scope of their amendment.
Lord Rea's motion (that the Bill be denied a second reading) will not pass, but he made a few good points. Rea argued that "there is no evidence that the Bill will reduce costs; rather the opposite", mentioning an FOI finding that FOI reveals 40 (mostly private) organisations have bid for commissioning training contracts, to be funded from money originally intended for postgraduate training.
Labour's Baroness Thornton told the Upper house that the Bill enjoys "no mandate, no evidence and no support - and has one of the worst Impact Assessments experts have ever seen, which shows no economic benefit".
She added that peers should "not be panicked, bullied or browbeaten ... there is an overwhelming call for us to stop this Bill. In a neat constitutuion-referencing touch, she suggested that NHS values offer a "dignified as well as an efficient role".
Bravura Bottomley
Virginia Bottomley's speech was as wonderful as you would expect. Yes, that good.
Alas, we did not get the classic anecdote about her having to ask M&S to open early during her era as Health Secretary because she was constantly getting interrupted by people telling her how well the NHS was doing under her leadership.
But we got something about how the NHS should be more like Tesco and have one chief executive for a very long time (suggesting that she knows too little of current and future Comrade-In-Chief Sir David Nicholson).
Then there was something about how the NHS occasionally needs muscular intervention from a regional chairman - who was a farmer, who gave out cheese and potatoes.
No, me neither.
Then there was the bit about why so many people are in prison.
No, me neither (again).
She concluded by implying that the NHS is shit, referencing a letter sent to her by someone who wanted the NHS to be there for their granddaughter, telling the chamber "I want my grandchildren to have high standards".
Lord Darzi didn't quite say that it's nice to be nice, but did say that "competition was a means; not an end in itself ... the right competition can drive us to reach for excellence, spark creativity and light fire of innovation". He also made useful points: "we in both Houses must stop out frequent assaults on NHS management - it may be good politics, but it's bad policy and in the long run, it will be self-defeating".
Darzi also asked, "who will improve quality as a system level rather than in individual organisations?". And then announced that he will support the Bill, which is philosophically opposed to central efforts to organise anything, let alone quality. Weird.
Lord Owen told the peers that "as health minister, I got into trouble for using word 'rationed' health service. I use it often. NHS remains extraordinarily popular with the public - why? because public think rationing fair and rooted in democracy. I was the first person to advocate an internal market in the NHS, but never thought it would lead to external true market ... Health is not a public utility. Health is different ... We should cherish the fact that the NHS is a pool of altrusism in our society".
His line on accountability was clearly-reasoned: "If we get it wrong, there will be serious pressure. There will be failures in hospitals and in CCGs. The public will find it difficult to accept that quangos decide how to deal with that failure".
Baroness Jay followed this up well, and Dame Joan Bakewell focused on the market and social care, with the obvious example of Southern Cross: "the old are not well-served by this Bill, and they are overwhelmingly the most frequent users of NHS services".
Lords Mawson and Warner were among many who offered strong support.
Labour's Dame Helena Kennedy told the chamber, “Monitor will be the economic regulator under part 3 of the Bill, It will be the regulator’s duty to sniff out and eliminate anti-competitive behaviour. And, of course, promote competition. According to the explanatory notes it is modelled on precedents from the utilities, rail and telecom industries. If anything should be a warning to the public that this spells catastrophe, it should be that this is another step in the disastrous selling off of the family silver to the private sector with the public held to ransom and quality becoming second to profitability. With the consumer powerless to really do anything.
“The regulator, Monitor, will have the power to fine hospital trusts 10% of their incomes for anti-competitive behaviour. What any decent doctor will tell you is that for seamless efficient care for patients, integration is key to improving the quality of life and patient experience.
"So the question is whether competition and integration can co-exist. Evidence from the Netherlands is – they can’t. There, market-style health reforms designed to promote competitive behaviour have meant that healthcare providers have been prevented from entering into agreements that restrict competition and networks between GPs, geriatricians, nursing homes and social care have been ruled anti-competitive.
"So there is fear that care pathways and integrated services and equitable access to care will be lost, when placed second to market interests.
“This has been a 25-year project. Done by stealth and started with the purchaser-provider split. We began with an internal market, and are now moving to an external market. This was not thought up by mere politicians, but by the money men. The people who brought us the banking crisis.”
We had a very powerful speech from Baroness Jenny Tonge, refuting Lord Darzi's argument that mid-reform NHS is the patient anaethetised, on the table, mid-operation so we can't stop now: "imagine Lord Darzi's patient on operating table had not given consent properly ... it is better to stop now and think". She concluded, "I say this in great sadness my party is taking part in what I and my NHS colleagues see as the destruction of the NHS - we should be ashamed of this. I am".
Paul Corrigan's wife Baroness Armstrong also made a strong anti-Bill speech, and Baroness O'Neill also offered forensic analysis.
Lord Adebowale made some superb points: "The leaders of the RCGP and BMA are really not in favour of the Bill; we have to listen to them. I don't believe the line they are not representative of general sentiment. I think we have a problem ... competition can waste resources; you have to emphasise collaboration ... nequality is not just wrong, it's also very, very expensive ... I don't care whether the Secretary Of State says he is accountable; he will be. He will be".
And Lord Crisp (with whom vintage readers will know I have form) gave an absolutely excellent speech. "The NHS has improved but needs continuing improvement. The Bill is a wasted opportunity, and is missing the main issues facing the NHS - it's still too hospital- and doctor-focused, and needs to be community- and people-focused. This is partly due to the process (I exempt Lord Howe from this).
"The NHS is a social contract, but it's moving towards a set of commercial contracts. It is about solidarity & trust. The levers of markets and GPs will just not be enough to achieve the change we need ... The Secretary Of State responsibility issue is about perception, reality and trust. The Government needs to address this, and make it clear.
"In my experience, the introduction of competition into the NHS really worked .... the threat of ISTCs really worked. New entrants are important .... (but) will competition law stop mergers? Can the Minister tell us what the limits are to markets?
Lord Crisp concluded, "The Bill can be improved, but we need enough time to do so. We need to maintain the NHS as a social contract; not a commercial one".