Health Bill [HL]

My Lords, I congratulate the noble Lord, Lord Darzi, on bringing forward his first Bill for consideration by the House. I must declare an interest in Clauses 18 to 22. Unfortunately, I am one of those people who have not yet managed to give up; that is something that your Lordships ought to know. I also make it quite clear that the policy that I will outline from these Benches about the tobacco control measures has been worked on with my colleagues here and in another place, who vary only in the degree of their intensity of anti-smoking feeling. During debate on the Queen’s Speech a few months ago, I tried to set out some of the enormous challenges that the NHS, our largest public service, will face over the next five years during a time of recession. As we go through the Bill, we need to bear in mind that now, more than ever, people want evidence that the NHS provides high quality, efficient services delivered personally, locally and nationally. That is why my colleagues and I continue to believe that locally accountable health boards are an important way forward, which, working in partnership with local authorities and voluntary organisations, are the best way to ensure accountability and transparency of services. I start with the constitution. The first and obvious point is that it is not a constitution; I do not know what it is, but it is not a constitution. I understand from talking to people, including some of those who worked on it, that this statement of intent, or whatever it is, should not be used by individual patients to further arguments with clinicians. Rather, it sets out the general relationship between the NHS and its patients. As such, it is an important document which tries to set out some strategic issues that have a big influence on healthcare. For that reason, we on these Benches have two regrets: two issues are missing. The first is a statement of clear principles about the use of patient data. I do not want to rerun the arguments made by the noble Lord, Lord Turnbull, but that is an ongoing issue that has never been resolved. Patients are fearful of confidentiality being breached, and researchers are frustrated by lack of access to anonymised data. That key point should have been included. Secondly, as the Local Government Association points out, if we are to reach the stated aims of overcoming health poverty, reducing mortality and improving efficiency and delivery of care, there needs to be full co-operation between the NHS and local government. I regret that there is no requirement on the NHS fully to co-operate with local government in the document. What is the document’s status in relation to existing policy and legislation? Important drivers for healthcare for several years have been the Children Act 1989 and the Mental Health Act 1983. I do not want those important pieces of legislation to be undermined in any way by this document, the status of which is unclear. Reviewing the handbook seems to be like a Forth Road Bridge job—never-ending. Reviewing it every three years seems to me quite daft. The pace of change in the NHS is such that you cannot fully implement something and review it successfully during that period, so we will propose later that the figure be changed to five years. On quality accounts, the NHS is swimming in data; it has data everywhere. It does not have a clear, purposeful system for analysing and using that data. We support the aims of the noble Lord, Lord Darzi, and we welcome the involvement of clinicians in setting quality accounts, but to ensure that the provisions are right we need a much fuller statement about the purpose of quality accounts. Then we can determine what their nature should be. We will support anything that helps the NHS to come up with verifiable data that improves its evidence base. We support individual budgets and direct payments as a means of making services responsive to need. I welcome any initiative that will enable older people to have greater independence, that will enable people to manage pain by having a chiropractor or an osteopath treat them, and that will help people with mental health problems to get rapid access to therapies, whether or not they are provided in their area. Direct payments are, however, very complicated. I told the noble Baroness, Lady Campbell, before she left the Chamber that I would tell the House that we need to be very clear that the use of direct payments in social care has yielded very little evidence so far. That evidence suggests that they work very well for some people, but for other people they are incredibly problematic. I am sorry to say that the noble Baroness, Lady Campbell, presented a particular view that may not be typical, and I am really worried that we see individual budgets as the answer to the NHS and all its problems when they are not, although they might be an answer for some people. I ask noble Lords to consider that the individual budget is a market model, which is interesting; when the City is ditching market models at a hell of a rate, we are suggesting that they move into the NHS. They have been trialled in social care, which has 28,000 providers, most of which provide stand-alone services, and if the providers fail, there is no knock-on consequence for anything else at all. In social care, services are managed by eligibility criteria and people’s ability to pay, and we are going to apply that to the NHS, which has a few hundred providers. In the NHS, the distinction between acute care and community care is not clear-cut, and taking a budget from one part of the organisation could have severe knock-on consequences for another. All those services are supposed to be free at the point of delivery at the moment and are largely uncosted; yet we are going to do all that on the basis of some very thin evidence from social care. That is a huge risk. We assume that this system will work, but we must realise that this is a system in which there are more providers and more capacity than people need, so they can have a choice and there is sufficient purchasing power. Noble Lords may think that that applies to the NHS today, but I ask them to consider whether it will apply in five years’ time. The IBSEN study has shown that there are some problems. I do not want to go into them; other people have, but if we go ahead without having fully evaluated this we will be in danger of compounding inequities between different client groups. That would be extremely dangerous. I say to the Minister now that we will not let the Bill leave the House without much more rigorous requirements for review and evaluation before this is rolled out. Innovation prizes are okay on one condition: that the Minister gives an undertaking that the money will not come from existing research, education and training budgets. If he says that, that is fine; he can have them. On tobacco control, we on these Benches, like everyone else, have seen all the evidence that has been put before us. It is regrettable that we have to consider this without a comprehensive strategy from the Government to counteract the illness and health inequalities that are caused by tobacco. I make the observation that tobacco is like any product; if there is a market for it, there is profit to be made, manufacturers will make it and distribute it and retailers will sell it. I will not restate the point made about vending machines, but I will say that we are a little sceptical about the extent to which the measures in the Bill will limit access by young people. I want to make it absolutely clear that we support the end of point-of-sale advertising, but we do not believe at this stage that it is right to end point-of-sale display. We would be happy to consider anything that noble Lords wish to put forward on plain packaging. We believe that, if stuff is put under the counter, it is glamorised and made more attractive to young people and smugglers are enabled to further their business. On pharmaceutical contracts, will the Minister explain whether the new system that he proposes will be used to decrease the number of pharmacies? Pharmacists are high street retailers and not immune from the carnage we see on our high streets at the moment, so we want it to be absolutely clear that the Government are not doing something that will decrease coverage. On adult social care complaints, I thank the Government for listening to what we said on the Health and Social Care Bill, but it is important that the local commissioner has a duty to refer any investigations to the regulator. That is how he will pick up incidences of bad practice and malpractice. Over the next five years the outlook for the NHS and local authorities in terms of funding is grim. I hope that, as we go through the Bill, not only do we keep in mind the long-term vision of the noble Lord, Lord Darzi, but we also ask ourselves this: will what we are doing make the NHS something that people continue to value and cherish in good times and in bad? Some parts of the Bill will help that, some may not, and on some it is unclear. Those parts which are good will have our support.