My Lords, I add my own warm congratulations to my noble friend Lord Stevens of Birmingham on his excellent maiden speech.
One of the most dispiriting and dislocating experiences that any large organisation can suffer is to be subjected to repeated waves of substantial reorganisation. It diverts attention away from the delivery of outputs and on to issues of structure and process, and just as, and often before, one set of changes is embedded, another looms. This leads to confusion, reduced efficiency and poor morale. So the Bill, representing another upheaval for the NHS, carries considerable risk.
I acknowledge that some of what it proposes goes with the grain of evolving practices in parts of the NHS and that it incorporates a number of welcome changes. The shift to a more integrated approach to health and care is long overdue, and the abandonment of the competition straitjacket will be cheered by the vast majority of practitioners. The question remains, however, whether such improvements could have been secured in a way that would be less dislocating for the NHS.
It is important to remember that a Bill such as this sets only a broad framework and that giving it effect requires a great deal of subsequent detailed work. At a time when Covid continues to stretch the NHS and the medical profession, perhaps even more so in the months ahead, does this represent the best use of scarce resources?
Turning to points of detail, in the time available I will touch on just one provision that the Bill does contain and two that it does not. Like other noble Lords, I worry about providing for increased political control over managerial decisions. I can understand how frustrating it might be for Ministers to have no control over decisions but nevertheless to have to bear the public and political consequences of them, but they need to ask themselves whether their closer involvement in the process is likely to lead to better decisions. I fear not. We have seen in the past that political priorities, often driven by dramatic headlines, are likely to be out of kilter with long-term health strategies.
While I am on the subject of strategies, I am disappointed that the Bill has nothing meaningful to say about planning and delivering the future NHS workforce. A quinquennial description of a system does not constitute a strategic response. Effective personnel planning has a simple equation at its heart: workforce equals the average annual intake times the average return of service. All three elements of this equation are crucial. The workforce requirement must be defined, and recruiting and retention must be appropriately balanced to maintain the right spread of experience and expertise. At the moment, we have no idea of the requirement, but we know that we are not training enough medical personnel and that retention is poor and getting worse. If we do not take urgent action to address these problems, none of the proposals in the Bill, no matter how worth while, will make a substantial difference.
The most pressing need is to improve retention. Defining the requirement and increasing recruitment are important but they will take some time to have an effect. Stemming and, if possible, reversing the increasing
outflow of trained personnel will have the quickest impact on capacity. On a number of occasions, I have asked the Minister’s predecessors what actions are being taken to address the problem and received nothing but vague reassurances. Meanwhile, the situation has worsened. Will the Minister now undertake to set up an empowered task force to remedy this crucial situation?
Finally, I have pointed out in previous debates that the NHS is an ungoverned system in that it faces ever-increasing demand and ever-increasing technological opportunity. No enterprise can succeed in the long term unless it manages its outputs as well as its inputs. At the moment, the NHS’s outputs are varied on a haphazard and sometimes irrational basis, often through uncontrolled waiting lists. Unless and until we face up to the fact that the NHS cannot do everything, we will never have a properly governed system. Because of the imbalance between growing demand and opportunity on the one hand and inevitably limited resources on the other, healthcare is rationed always and everywhere. The question for us is whether we wish to devise a fair way of doing that or to continue with our present, incoherent system of force majeure.
The current Bill, like all its predecessors, has nothing to say about this. It therefore treats a number of distressing symptoms but does not address the underlying condition that threatens the long-term well-being of the NHS. In this regard, it is another missed opportunity.
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