Fri, 08 Jul 2011
Speaking at the NHS Confederation Annual Conference today [Friday], Liberal Democrat peer Baroness (Shirley) Williams said:
"The passage of Mr Andrew Lansley’s Health and Social Care bill through Parliament has been attended by growing concern and confusion. Initially only a small number of politicians and journalists, among them the Financial Times’ Philip Stephens, and a few prominent members of the medical profession, sounded alarm bells. Most people thought of the bill in the context of the General Election campaign and the subsequent Coalition Agreement, that nothing fundamental would change.
"By the beginning of this year, attitudes began to alter. The Royal Colleges, the elite of the medical profession, began to ask searching questions. So did a few peers and MPs. At the Spring Conference of the Liberal Democrats in Sheffield, a group of concerned representatives, several of them men and women with long experience of the NHS, including Dr Evan Harris, former MP for Oxfordshire West, drafted a resolution for the Conference expressing their strong reservations about the proposals. The conference passed the motion overwhelmingly.
"Their anxieties were taken up by the Liberal Democrat leader, Nick Clegg, and by some members of the official Labour opposition. Clegg studied the Bill, and argued relentlessly for the changes he and the Liberal Democrats believed to be essential for the future of the NHS as a public service. Discussions between the Coalition leaders led to the listening exercise by the NHS Future Forum, chaired by Professor Steve Field, and the publication of the detailed recommendations in the Forum’s report. There were three significant developments which I shall now set out.
"First, the listening exercise was just what it claimed to be. Professor Field and his associates spoke to hundreds of people –members of the public, of the medical professions, of the NHS staff, of local authorities and many more. The report reflected those many conversations. It proposed substantial changes to the legislation, while upholding some of the best elements in the Lansley proposals such as integrated health and social care, the emphasis on preventive health policies, patient involvement and the role of local authorities in the delivery of health services.
"Second, the medical professions demonstrated impressive loyalty to the idea of health as a public service. I have been in public life long enough to know how the pursuit of status and money can deform and even destroy principles and values, even in the most admirable of vocations. Nevertheless, the evident commitment to the NHS demonstrated in the listening exercise by so many doctors, nurses, administrators and NHS staff, to the concept of a public service accessible to all and free at the point of need, remains impressively strong.
"Third, the significance of some of the proposals for change, and the urgent need for them, came across in the exercise, driven by growing awareness of the scale of the challenge facing us all: a financial debt that sharply curtails public expenditure, a much longer expectation of life and therefore of the proportion of elderly people in our society, and the increased need for health care for them, and also of many people with chronic illnesses or conditions who now thankfully live on into old age. The NHS’s problems are partly bred by its own success.
These developments do raise some large issues I shall not pursue further today, though I hope the Confederation and others will consider them. “No decision about me without me” is a two sided commitment – for all of us must bear some responsibility for our own health. As a society we need to address self-inflicted illness, whether from lack of exercise, inadvisable diets, excessive drinking or uncontrolled violent behaviour.
"Valuable though it has been, the listening exercise – the pause – has also been costly in money and time. Every week that passes makes the achievement of the necessary efficiency savings more difficult. The NHS goes on losing good staff, and paying people for redundancy. It is today a shell of its former self. The listening exercise, while offering welcome opportunities to the profession and the public, has entailed a major redrafting of the Bill, so much so that some have called for us all to draft a completely new bill. And there is something a little odd in listening – really listening – for eight weeks followed by a rushed Parliamentary response in which all the amendments and recommendations have to be dealt with in just five days. Some of the wiser proposals may be lost in the scramble to produce a redrafted Bill to be voted on in less than a week’s time.
"Despite the pressures, the moment must be seized. The Bill is in places still confusing, obscure and ambiguous. It would be easier to amend at this stage than in its later passage through both Houses of Parliament, though undoubtedly the House of Lords with its eminent medical contingent will have substantial ideas for improvement.
"I welcome many of the recommendations made by the Future Forum, the emphases on transparency and openness, the far-reaching changes in the composition and government of the clinical consortia to bring in people knowledgeable about secondary care, nursing, public health and indeed lay people in a senior position; to ensure that the exciting work of the specialist networks is made available through direct advice and local senates; to require that the consortia meet in public and respond to public concerns, a proposal that extends even to foundation trusts, all these changes are responses to strongly expressed concerns.
"But I would be less than candid if I failed to mention that there are still some unresolved and troubling issues to be addressed. Fundamental to the whole edifice is the role of the Secretary of State. Despite the new clause on the Secretary of State’s duty to promote a comprehensive health service, it remains far from clear whether this amounts to a duty to provide or secure the provision of health services. There are new provisions for the Secretary of State to intervene if there is a significant failure in the duty of the National Commissioning Board or the clinical consortia to arrange the necessary services. But in a recent letter from the Minister of State, it was made clear that the Secretary of State will have no default duty to provide these services himself. In other words we are still in a shadowy area where nothing is clear; legal advisers tell me that the current Bill ‘s words, enticing though they may be, do not add up to a duty to provide a comprehensive health service as laid down in the 2006 NHS Act. It is vitally important that the position is made unambiguously clear.
"With regard to competition and choice, there are again some ambiguities, though the emphasis on quality rather than price and the transformed position of Monitor are reassuring. I am concerned about the removal of the cap on private beds in foundation hospitals, not least because the mixture of NHS patients with private ones provides a better basis for the training of young clinicians, as well as ensuring outstanding medical practice to less advantaged patients. As for choice, many elderly or frail patients prefer a good local hospital or home-based community care to making complex comparisons. The idea of a personal health budget would be better expressed as a personal care budget, given the new ideas on how to finance care of the elderly.
"The training of NHS staff is in the end the best guarantee of the quality of health care. NHS staff need to feel part of the whole enterprise – one reason why I do not favour outsourcing of tasks like cleaning in hospitals. They also need to be praised and defended, for they have been daily in the health care front line. We need to think what sanctions can be applied to those members of the public who abuse them or swear at them simply for doing their job. The role of nurses is very important, and many of us regret the disappearance of state-enrolled nurses, the front line of communication with patients as well as doctors.
"As for the training of doctors, I hope we will keep the deaneries and the precious link between medical schools and the hands-on experience of practice in the wards. The Government response refers to the transition period but this is a system of training that has proved itself. I hope too that the silly idea of limiting the period Commonwealth and non-EU trainee doctors can spend here in the UK to one year will be dropped. It makes no sense medically, and these guest medics play an important part in NHS provision, as well as carrying their valuable experience back to their own countries. Finally the experience of hospices and the burgeoning of patient groups, especially among those with rare or complex conditions, shows how much the wider society can contribute to better health. It is yet another of the new lessons to be learned.
"Nobody should minimise the challenge facing our health services. But let us say loud and clear, as both the US Commonwealth Fund study and the OECD have done, that ours is one of the most accessible, fair and cost-efficient health services anywhere in the world. Given closer integration of health services, and greater transparency and accountability, it could become the model of the best there is. We, politicians of all parties, must now give the medical community the stability and the space it needs to deliver that promise."
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