My Lords, I draw attention to my interest in the register as chair of Royal Brompton and Harefield hospitals, now part of Guy’s and St Thomas’ Trust. Like others, I pay tribute
to both the speech and the work of the noble Lord, Lord Stevens, and thank him for assisting us in making a merger of two trusts work where both sides wanted to do it.
Like so many of us, I am hugely proud of the NHS, its formation and its evolution, but I am also hard-headed. To be funded properly and remain broadly supported as a universal service, it needs consistent investment and intelligent, well-evidenced reform. I was aware of that before the 1997 general election, when I felt that the very foundation of a universal service was at stake. Underneath the warm noise, I feel that somewhat now again. I am hugely supportive—indeed, incredulous—of those who work in the NHS, but that must not morph into unconditional support without challenge for the outcomes and delivery of the service around the country.
I have spent more time, really, connected to a different public service—education—where arguably there has been a more sustained principle of reform for 20 years or more. We have seen a sustained push to raise standards across the piece, with a particular focus on under-attainment and disadvantage. We have seen devolution of budgets and responsibility to the front line, clear accountability and action on failure, facilitated by inspection and data, and support for getting talented people into teaching and leadership. Do not get me wrong: it has not all been rosy, and I have had many disagreements, but today is not the time for that. My point is that there has been a visible approach and journey over the last couple of decades.
Contrast that with health: centralisation, then decentralisation; PCTs; SHAs; CCGs; regional NHS bodies; Monitor; NHS England and NHS Improvement —then merged; we could all go on. Now we have ICSs, acute collaboratives, myriad reviews and too many meetings and demands for information. Those demands are made on the very people who are trying to deliver services for patients all the time.
The Bill, laudably, aims to improve and move the NHS from a siloed approach to a properly comprehensive system of health and care. It wants patients to be treated at the right time and in the right place and outcomes and treatments to be more equitable. Who would not support that? Of course we want greater integration; it makes complete sense, but the devil is in the detail. What I and, I suspect, others will want to understand during the passage of the Bill is how it will improve outcomes—or will it simply even things out? Will there be action on failure or a soggy “Let’s all help each other out”? By that, I do not mean shouting at press conferences at overstretched people, because we all know that simply will not work.
Will there be space to encourage clinicians, managers, scientists and entrepreneurs to be innovative and drive new practice and efficiencies? Will there be incentives to get improvement? Will AI and machine learning really be exploited? Where is the focus on life sciences to harness the huge opportunity that a national health service offers? Will data be used to empower patients, and will data systems work so people are not tied up with endless requests from the layers—using different data systems, of course?
I also wonder whether Covid “gold” has, understandably, in many ways allowed a command-and-control system to become paramount. How we will turn that back to allow talent and ideas to flourish, or will that be sacrificed? I have to say that the Statement from the department on foundation trusts and capital is a warning sign for me. We must incentivise performance at the front line.
Will the really hard issues be examined and reformed—I am thinking particularly of primary and community care—or will that be left to “working together”, with the usual focus on hospitals, albeit probably through the parallel acute collaboratives? Crucially—others have said this far better than me—where is the comprehensive workforce plan? Without it, too much of this will be hot air.
I suppose I am sceptical—and I do want to be convinced—because I find it unusual, let us say, to see integration leading to extra layers and bureaucracy. Of course I want better partnership, better leadership and better care and for that to be spread widely around the country. But I have to say that my experience as an NHS chair for four years has been that good governance has to be tangible, transparent and provide clear differentiated responsibilities and accountabilities. You need strong and effective boards with a range of backgrounds and experience, and I do not really see this here. The governance is a muddle and I suppose that in some ways, I am arguing that I do not think it is bold enough.
I get the arguments for more integration of local care—of course that makes sense—but I do not yet see the Bill delivering what we really need. My plea is that, together, we really examine the Bill on the basis of why, what, how and who. Otherwise, we will end up doing another set of reforms five years from now and will not deliver the modern, integrated, universally supported system we all need and want. Please let us take the chance to get this right, or at least make it much better than now.
9.08 pm