Lamb on NHS (60th Anniversary)

12.48.48pm UTC (GMT +0000) Thu 26th Jun 2008

' . . it was a Liberal, William Beveridge, who laid the foundation stones of the NHS. It is a pity that the Liberal Democrats have not yet had the opportunity to administer the national health service, but one day our turn will come . . '

[Jun 25] Norman Lamb (Shadow Secretary of State for Health, Health; North Norfolk, Liberal Democrat): I am pleased to join in celebrating the 60th anniversary of the NHS. It is right to acknowledge and express appreciation for the massive contribution of the staff in the NHS, from those at the bottom of the organisation to the most specialist clinicians. The motion also rightly identifies the role of volunteers and charitable organisations, which often work in partnership with the NHS. They play a vital role, and are often staffed by people who have had a particular experience, or whose loved ones have, and who demonstrate a real commitment to the care provided.

It is also right to acknowledge and celebrate the extraordinary founding principle of the NHS-that everyone, irrespective of income, should have the same access to care, based on need, not on ability to pay. As the other two Members who have spoken have acknowledged, it was a Liberal, William Beveridge, who laid the foundation stones of the NHS. It is a pity that the Liberal Democrats have not yet had the opportunity to administer the national health service, but one day our turn will come.

We should never be complacent about the future of the NHS, its safety and security. It could be undermined by two factors: first, funding levels; and secondly, the way in which the money is spent.

Back in 1997, at the end of the Conservative Government, this country was spending a third less than the average European spend on health. The consequences were there for all to see. Hospitals were decaying, and not enough doctors, nurses or other health professionals were being trained or recruited. There were real weaknesses. At the end of the Conservative years in government, whether we look at cancer, heart disease or stroke care, the outcomes-the issue on which the Conservative spokesman focused-for people in this country were poor compared with those in other European Union countries.

Today, a difference has been made to funding. This country now spends about £100 billion a year, which is a dramatic increase in investment in the health service. We supported that all the way through. We called for it in 1997, and when it came we supported it in votes in this Parliament. Given that funding has increased, however, we must ask, first, whether we are getting enough out of the investment, and secondly, how the NHS will cope with the challenges of the future.

As has been said, the current spend is at about the European average. Yet, as the Conservative spokesman has said, our outcomes still lag behind Europe's on heart disease, cancer, stroke care-

Andrew Lansley (Shadow Secretary of State for Health, Health; South Cambridgeshire, Conservative): And lung disease.

Norman Lamb (Shadow Secretary of State for Health, Health; North Norfolk, Liberal Democrat): Indeed.

This country has gross inequalities in health outcomes. That issue has not been focused on particularly in this debate, but we ought to focus on it. Health inequalities in this country continue to be completely unacceptable, and indicators suggest that they are getting worse, not better. I fully recognise that the causes of those inequalities are often well beyond the remit of the national health service, but the NHS has a role to play. Part of that role is to ensure equal access to health care, which we simply do not have at the moment, and that should be addressed. In some areas of health care, particularly those which are not subject to targets, access is still poor. I want to focus on mental health.

Under the Freedom of Information Act, we did a survey asking mental health trusts across the country how long people have to wait for access to cognitive behavioural therapy. In some parts of the country, people have to wait more than two years; in many areas, the wait is more than one year. Given the view of clinicians that outcomes improve significantly as a result of early access to such treatment, it remains a scandal that people are having to wait so long for something that could make a real difference to them. One of the themes on which I want my party to continue to focus is the inequality between the treatment of patients suffering from mental health problems and the treatment of those suffering from physical health problems. That disparity cannot be justified, and must be remedied.

In recent years, when trusts throughout the country got into financial difficulties and trusts were forced to deal with their balances, it was public health budgets that suffered, although they can do so much to prevent health problems from developing in the first place. The experiment that has taken place over the past decade, involving top-down command and control and big government, has clearly been found wanting. It has failed in so many respects.

We see gross waste and inefficiency, and a dependency culture in which no innovation takes place at local level because the Government dictate everything to primary care trusts and hospitals. We see funding that always has strings attached, because the Government know best how the money should be spent. We see micro-management from Whitehall: the Government tell every hospital in the country to undertake a deep clean, at vast expense. The clinicians tell us that that is not the best way to tackle hospital-acquired infections; but the Government know best. Then there is the debacle of the Medical Training Application Service- [Interruption.] Does the hon. Member for Cleethorpes (Shona McIsaac) wish to intervene? It appears that she does not.

I was talking about the MTAS debacle. The Government sought to impose an entirely new system for the recruitment and selection of junior doctors throughout the country without piloting it first to establish whether it would work, leaving chaos in its wake. Similarly, we have an IT system that has been imposed from the centre.

Sandra Gidley (Shadow Minister, Health; Romsey, Liberal Democrat): We do not have an IT system!

Norman Lamb (Shadow Secretary of State for Health, Health; North Norfolk, Liberal Democrat): The crux of the problem is that, as my hon. Friend says, we do not have an IT system. It was a system designed in Whitehall, a political imperative. No cost-benefit analysis was undertaken. There was no proper review to ensure that people who were building the system, the people who were paying for it and the people who were using it understood the same thing. Nothing like that happened; all that was undertaken was a massive commitment to spend over very many years. What do we see now? We see the whole scheme running years behind schedule, according to the National Audit Office, and we see the total cost massively above budget.

We see polyclinics-sorry, GP-led health centres-being imposed on every primary care trust in the country. The Secretary of State sought to defend that, but it is indefensible. It is not sensible to tell every primary care trust that it must have a GP-led health centre and that contracts must be concluded before the end of this year. Again, that is dictating to the health service because of political priorities and political imperatives rather than sound clinical judgment.

Stephen Hesford (PPS (Vera Baird QC, Solicitor General), Law Officers' Department; Wirral West, Labour): Does the hon. Gentleman not understand that without some form of direction from the centre, without someone trying to organise what should happen around the country for equity's sake, the postcode lottery would come into the picture?

Norman Lamb (Shadow Secretary of State for Health, Health; North Norfolk, Liberal Democrat): The remarkable answer to that is that we have a postcode lottery now. It is alive and kicking, and we have no accountability for it. Around the country, bureaucrats and people appointed centrally are making the decisions about access to health care. They are not accountable to the communities that they serve. We have the very problem to which the hon. Gentleman refers under our existing highly centralised system. The hon. Gentleman shakes his head, but we have it: it is there for everyone to see.

We have a myriad bureaucratic targets, which are often contradictory and have unintended consequences. Unlike the Conservatives, I see a role for targets. Every well-run organisation has targets to improve its performance. In the private sector every good organisation has targets, and for the Conservatives to speak of getting rid of all targets seems utterly bizarre to me.

Stephen O'Brien (Shadow Minister, Health; Eddisbury, Conservative): National targets.

Norman Lamb (Shadow Secretary of State for Health, Health; North Norfolk, Liberal Democrat): That is helpful, but I shall return to the subject.

Stephen O'Brien (Shadow Minister, Health; Eddisbury, Conservative): Leave that bit out.

Norman Lamb (Shadow Secretary of State for Health, Health; North Norfolk, Liberal Democrat): Despite that suggestion, I will not leave it out, because it is a central issue that needs to be addressed.

We see endless botched reorganisations, and with every reorganisation come more payoffs to senior executives. They drive clinicians crazy, and they certainly drive the public crazy. A recent example is the enormous payoff-£700,000-to a chief executive of a hospital trust in Leicester, aged 52, who now receives a pension of some £60,000 a year while also working as a consultant for the Healthcare Commission. That sort of waste of money drives people mad.

We are not the only people who say that the health service is ludicrously over-centralised. As she reached the end of her troubled tenure last year, the former Secretary of State, the right hon. Member for Leicester, West (Ms Hewitt), made a speech to the London School of Economics in which she described the NHS as

"four times the size of the Cuban economy and more centralised."

That seems to me to describe it rather well, and I suspect that the right hon. Lady was in the best position to make the judgment, having tried to control the beast for so long.

This, then, is Labour's NHS: loads of cash, the right instincts certainly, but dreadful waste and inefficiency and an absolute failure to let go. Interestingly, the Labour manifesto at the last general election made a bold claim-promise, indeed-to cut the number of staff in the Department of Health by a third, and to halve the number of quangos. Neither, of course, has happened. When we asked a question about the number of people working in the Department, the answer suggested that it was pretty much the same as the number three years ago.

How can we meet the challenges of the future better than the top-down, command-and-control approach that has proved so wasteful over the past 10 years? We face enormous cost pressures in a modern health service. New technologies are emerging, and new drugs are constantly being developed. There is a continuing debate about top-ups and about how on earth we are to fund new drugs which, in many cases, can provide good clinical benefits but may not meet the NICE criteria for public funding. We face all the challenges posed by lifestyle conditions such as obesity, alcohol consumption and smoking; and, critically, we have a massively ageing population.

I recently met a specialist in mental illness in the elderly in Liverpool. He showed me a graph showing the number of centenarians in our society over the next 50 years. It was frightening to observe the growth in the number of people who will reach the age of 100. At the same time, the ratio of people of working age to older people will change dramatically, so we are losing the work force that will provide the care for older people. Therefore, we face massive challenges. As well as all the extra cost pressures, we have to recognise that patients now expect something different. Nowadays, in all aspects of life, people behave as consumers-they want to make their own decisions and to have control over their lives. That is the case in health care as well, and the NHS must adapt to that. On top of all these matters, tackling the gross health inequalities that continue to afflict our country must be a priority in the years ahead.

What is the Conservatives' solution? First, let me say that they are right to focus on outcomes. There can only be any point in all of this vast amount of public spending if we manage to make people stay healthier and live healthy, longer lives; that is the aim. However, that focus is only a partial solution, as willing the end does not always achieve delivery. We must always ask how we are going to achieve the improved outcomes that today's Conservative paper rightly points to the value of trying to achieve. Its approach is to scrap all national targets-to have no access incentives at all, as far as I can see. Under its plans, there will be no entitlements for individual patients across the country, wherever they live, to ensure that they get access to the health care they need.

It is worth remembering the origins of targets. They emerged when the new Government came to power in 1997 because of the dreadful and unacceptable waste under the previous Conservative Government. The political debate in 1997 focused particularly on the fact that people were waiting so long for treatment. I remember when I was first elected to Parliament in 2001 taking up cases on behalf of constituents who were waiting three or four years for orthopaedic operations-for hip and knee-joint operations. It is worth remembering what it was like; it was dreadful.

Therefore, I believe that access is an important issue in its own right. While waiting for treatment, people often suffer from anxiety and trauma. If they are waiting for a hip or knee-joint operation, when it finally takes place the outcome might demonstrate that the operation has been performed well, but if they have waited two years to have the operation, they will probably have waited in severe pain and will also probably have had a carer who had to cope with them in that condition during that period.

Andrew Lansley (Shadow Secretary of State for Health, Health; South Cambridgeshire, Conservative): The document we published today is expressly a follow-up to the autonomy and accountability paper that we published last year. It sets out to define the basis on which the Government agree with the NHS board-a more autonomous board-the structure of national objectives. That is not to say that the NHS board will not be responsible for issuing commissioning guidelines. It will be responsible for the contracting process between commissioners and providers. For services such as accident and emergency, there will be contractual conditions for the necessary quality. Patients' referral to treatment times will still be measured, and patients will still be able to exercise choice, and that choice will drive continuous improvement. It is important to be aware that what we are talking about is the national relationship between Governments and the NHS.

Norman Lamb (Shadow Secretary of State for Health, Health; North Norfolk, Liberal Democrat): That suggests to me that waiting time targets might re-emerge, either locally or through the independent board. [Interruption.] Well, if the Conservatives' conclusion is that they will not have either national or local targets or entitlements, I think there is a severe flaw in their overall package.

We must never take access for granted. To focus on outcomes almost assumes that access is a given, but we can never assume that that is the case. Just as we have managed to improve waiting times, they can easily slip-and we must remember those areas such as mental health where waiting times are horrendous. To abandon targets, and to have no access incentives and no entitlements for patients, will have potentially disastrous consequences. I also think it will run the real risk of worsening health inequalities. Our approach focuses on entitlements for patients and recognises entitlements to access treatment. It recognises that many people, who might not be articulate and understand how to play the system, will need help in exercising their choice and in making the right informed judgment. That is why we think that a network of patient advocates can help people in making the right decisions about their own health care.

Let me now turn to what I think the priorities should be for the future of the health service, and to what the Liberal Democrats' approach would be. Let me deal with the question of pruning back the role of the central state. I have made the case against the Government's approach, which stands alone, if one makes international comparisons, in the extent to which it seeks to control the delivery of health care from Government offices in the centre. It seems to me that the Government should focus on key functions such as, first, the fair distribution of resources around the country, so as to ensure-without political interference, incidentally-that the resources get to where the need is greatest. Secondly, it is right nationally to focus on high professional standards within the NHS. Yes, the Conservatives are right to focus on setting a framework for the delivery of improved outcomes, but it is also right to focus on the right to access to health care wherever people live in the country, and irrespective of their means.

So yes, our approach is to recognise that access is important and to introduce the idea of an entitlement to access treatment within a defined period. The system in Denmark works well there. The idea is that people get access to condition-specific treatment within a defined period, and if they do not receive the treatment, it is paid for by the locally elected health board, if necessary in the private sector. Interestingly, it has not led in Denmark to a haemorrhaging of patients to the private sector; rather, it has been the biggest single driver of improved efficiencies within the state hospital system. [ Interruption. ] It is absolutely not the patient passport, and the hon. Member is either being disingenuous or not understanding. The patient passport was a subsidy for people who could afford to top up the rest of their care for private treatment in the private sector. This system pays for a person's operation in its entirety. Crucially, in mental health, the person who has no resources to go to the private sector to circumvent the one-year wait for cognitive behavioural therapy would also be entitled to their treatment within that defined period, and if they did not get it, it would be paid for privately. That is giving real power to individuals, irrespective of their needs.

We also believe that we should be empowering local communities, democratising primary care trusts and imposing on all PCTs-locally elected health boards, as we would call them-a duty to ensure the efficient use of resources. The health think-tank Reform has talked about an economic constitution for the NHS. That is the right approach, ensuring that money is used most effectively. Compare that approach-empowering communities-with that of the Conservatives. At the moment, one person is democratically elected within the health service: the Secretary of State. The Conservatives would lose that one person and have an independent board that was not democratically accountable in any shape or form. Just imagine: when a local community faced the loss of their hospital, they would have no right to decide locally whether that hospital would close. Decisions would be made by unaccountable, unelected bodies nationally. At that stage, in my view, the wheels would come off.

The Secretary of State recognises that there is a democratic deficit within the health service but he appears unwilling to do anything about it. The Minister may well want to address that issue when he winds up the debate. We recognise that there must be democratic accountability within the health service. The Government recognise that there is a problem; what are they prepared to do about it?

Thirdly, we want to empower patients far more than they are at the moment. No longer can we accept the idea of care delivered from on high to grateful, passive recipients. People want to take charge of their care and they need, as the Conservative spokesman said, access to information so that they can make the right choices; but as I have said, they also need access to support in guiding them in making the right decision. We also support the idea of individual budgets being piloted in the NHS and of seeking to give people more control in coping with long-term chronic conditions and so on.

Our fourth principle is fairness, equity and addressing those health inequalities that scar our society. One of the issues that must be addressed is the fact that there is less access to primary care in poorer areas than in wealthier suburbs. The mechanism that the Government use is the central imposition of GP-led health centres, and they are also promising to bring more GP practices to impoverished areas, but surely the financial incentives to undertake primary care must also be addressed. At the moment, a GP receives more money if they practise in a wealthier area than they do if they practise in a poorer area. There should be financial incentives to encourage GPs to practise in those more challenging areas. We are developing the idea of a patient premium, whereby extra funding is attached to patients from deprived backgrounds to encourage GPs to provide support for those communities.

As the NHS reaches its 60th birthday, it is time for an injection of Liberal thinking, as there was at its very beginning. The NHS can adapt, evolve and prosper. I am passionate about giving power to those people who have no power in our system. That is as important a principle in health care as it is in any other walk of life. Communities, not Government, should be in the driving seat in shaping the delivery of local health services; patients should take control. Fast, efficient, high quality care should be guaranteed to patients, putting individuals before institutions. That is how we should build on the past successes of the NHS as we look ahead to the next 60 years.