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Debate on the Address

My Lords, I want to talk not so much about what is in the legislative programme on health—which is fine as far as it goes, and we shall have ample opportunity to talk about it—but about what I see as being missed out: legislative measures to support existing NHS reforms. The recent tragedy at Maidstone and Tunbridge Wells hospitals, to which my noble friend Lady Emerton alluded, where more than 90 people died of C. difficile infections, is no more than the visible tip of an iceberg of many NHS hospitals where we would not want our relatives to be cared for and where the standard of care is not only unacceptable but seemingly resistant to change. In my view, this is the inevitable outcome of 60 years of direct central management of the NHS from Whitehall. Some noble Lords will be thinking, ““Rubbish””, and that bad managers, second-rate clinicians and incompetent boards are to blame. As someone who has worked as a hospital consultant, a chief executive and a trust chair and who is now on the board of Monitor, the foundation trust regulator, I have direct experience of dealing over many years with the constricting chains of Department of Health management, where boards are regarded at best as largely irrelevant and at worst as a positive nuisance; where chief executives spend up to a quarter or more of their time ““feeding the beast”” while out at meetings of the hierarchy rather than on patient-related matters; where clinicians feel disempowered and removed from the responsibilities of management, although they spend all the money; and where the responsibility for training nurses and for generating the quality of care standards and so on is removed from the hospital to a remote body. I know that there are plenty of scandals in the independent sector care homes, too, which are the result of poor consumer pressure, no competition and ineffectual regulation. But in NHS hospitals it is the profoundly disempowering remote management that encourages NHS managers to fiddle with numerous edicts and instructions while the quality of services may be lamentable. The Government have begun to change things. Over the past decade of Labour government, and before that under Conservative Governments, there has been in this country a policy consensus that hospitals and community health and social care service providers must be freed up and moved from direct control to real, commercial-style autonomous boards with local accountability, where competition, plurality of providers and real choices for patients drive a regulated system judged on clinical and patient satisfaction outcomes, not on proxy process target measures. The system in health has been mirrored in the policy initiatives in education. We have come a long way in the past decade and I pay tribute to the Government for that. I have been very proud to be part of those reforms, which are now widely recognised as the right approach. Commissioners are focused on understanding local health needs and designing appropriate care pathways. There are real incentives for providers to give efficient, high-quality care through the payment-by-results tariff system and the introduction of real patient choice. Autonomous providers are free to make their own decisions on how best to deliver care that responds to patient and commissioner requirements quickly. The real challenge is whether the Government will keep up the pace of reform. Many of us have watched effective government policies slide into the ground, neglected and half-implemented after a change of Secretary of State. Stepping back at this stage will have grave consequences. But what was Gordon Brown's reaction to the news that, in the public's view, our hospitals are not getting clean enough fast enough? He issued an edict that all hospitals will have a ward-by-ward ““deep clean”” to rid them of fatal superbugs. He said that, "““walls, ceilings … and ventilation shafts””," across the country, "““will be disinfected and scrubbed clean””." That is the Prime Minister speaking about hospital ventilation shafts. What will he do when that fails? Will he send David Nicholson out to scrub the bedpans himself? That would be a long job. The noble Lord, Lord Darzi, will say that all US hospitals do the deep clean as a matter of course. Of course, UK hospitals should, too. Indeed, they used to. I participated in the ““high sweep”” as well as the ““deep clean””. The noble Baroness, Lady Emerton, obviously has done so, too, as she is nodding vigorously. I have no quarrel with the need, only the manner of the directive and the fact that once again the centre will determine action, not because hospitals see it as their priority. The Government must not bottle out and regress to the norm of issuing instructions on cleaning or anything else. If we trouble to look at the history, we will realise that that will not do a jot of good. We must have the courage to be patient and to hold fast to the benefits that we are beginning to see from the reforms in, for example, the NHS foundation trusts, which are delivering higher-quality care than NHS trusts in general. They are delivering strong financial performance. Last year, they delivered a surplus of £130 million and are becoming more efficient. Those people who do not see the point of surpluses should remember that no surplus means no investment, no growth and no improvement. All 19 organisations rated as excellent by the Healthcare Commission for use of resources and quality of services are foundation trusts. There is growing evidence of the beneficial impact of greater autonomy on foundation trust boards and on managers and clinicians. At Monitor we have now seen more than 100 boards in our very rigorous assessment process. Boards are taking greater ownership of the performance of their trusts. They are and they feel accountable for performance. That is important. Chairmen and boards are starting to behave differently. They see their trusts as autonomous businesses and their role as driving performance, which recruits better chairs. Boards are adopting more professional management approaches with the introduction of service line management, which empowers senior clinicians to take responsibility for their services and puts them in the driving seat. Let us not forget that there are an estimated 800,000 members of NHS foundation trusts, providing a direct link to patients and local communities. What an opportunity we have to use those members and governors creatively to influence the way our hospitals perform. Yet the Government forget they exist. We need to use those governors and members, who are an excellent vehicle for linking patients and the local community to influence the hospitals. To slow the pace of reform now, to hint at any return to command and control, would put this at risk. I am told, and the noble Lord, Lord Darzi, has repeated it, that there is no intention to reverse the process of reform. But I hear different mood music, a subtle silence that will not do. The word ““choice”” has disappeared from documents. Competition from the independent sector is no longer talked about. Yet unless there is overt, visible drive, the reforms will stop. The great NHS machine will see to that. Rather than slowing down, the Government need to step up the pace of reform, to build up the capacity of commissioners and to improve the range and quality of information on clinical outcomes that are available to patients and the public, both to inform choice and to stimulate clinicians to improve their own results. We have the mortality data, which is a start. We need far greater outcomes data. We must support boards, senior managers and clinicians in developing the capabilities that they have to empower front-line staff and lead high-performing organisations. In Monitor we have tried to do a number of things. I have mentioned service line reporting. We have introduced with the Cass Business School at City University a tailored training programme for finance directors to help them to make best use of the freedoms offered to foundation trusts. We are developing a training programme for non-executive directors to help them to challenge their executive directors more effectively and to help to drive performance. The review that the noble Lord, Lord Darzi, is undertaking provides an excellent opportunity for the Government to cement their commitment to reform. If the reforms are combined with effective regulation, which I hope we will see from the forthcoming Bill, we will have a chance of sustainable improvements in our health and social care services.