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Welcome changes to the Health Bill

June 14, 2011

The Government’s NHS and Social Care Bill is now back on track and much improved.  The “pause” has been worthwhile and we now have a much better Bill.  It was clear to me and to my Liberal Democrat colleagues that while the NHS is in need of reform to respond to the growing societal demands upon it, the approach in the original Bill was not on the right lines.  The Liberal Democrat conference in March called for various amendments to the Bill, in particular making it clear that we need collaboration not competition in health care.

I have also been keen to see more democratic local oversight of the planning of health services in Bristol. When I became the MP for Bristol West in May 2005 I was on a steep learning curve to understand how decisions were made about the local NHS.  At that time I had to meet with two Primary Care Trusts, two hospital trusts, the mental health trust and the strategic health authority.  In the last 6 years there have been numerous reorganisations, chief execs and board members have come and gone.  The fact is that if you asked anyone on Gloucester Road who runs the NHS in Bristol they wouldn’t have the faintest idea!  So as well as a need to reform the NHS so it can deal with an ageing population, new clinical challenges and rising costs there was also a need to address a democratic deficit.

The changes to the Bill are a direct result of Liberal Democrats working positively within the Coalition Government and agreements made between the Prime Minister, Deputy Prime Minister Nick Clegg and the Health Secretary.   The Bill will now recommence its House of Commons committee stage for detailed consideration of the Government’s amendments.

Firstly, the Bill will reaffirm the statement in the original 1946 NHS Act of Aneurin Bevan that the Secretary of State is responsible for securing a comprehensive national health service.  This will duty be in line with the NHS constitution and will ensure that the interest of patients remains the paramount consideration.

But I am personally delighted to say that this responsibility will be augmented by a new duty to narrow health inequalities. I chair Parliament’s cross party committee on smoking and public health.  For me, tackling the underlying causes of ill health such as smoking, alcohol abuse and other factors is much more important than reform of the bureaucracy of the NHS.

Integration and co-operation within the health service is vital if we are to get on top of the chronic diseases that beset an ageing population. The framework for allowing patients to choose from non-NHS providers will largely mirror the arrangements put in place by the last Labour government but without the cherry picking, price competition and extra payments that they encouraged.  The organisation set up by the last government to regulate competition and “contestability” within the health service, “Monitor”, will now be tasked with promoting collaboration and quality, rather than competition.  There will be no “cherry picking” of profitable services by the private sector and certainly no “privatisation”, which was never on the agenda but was the subject of much scaremongering.

What will actually happen in Bristol is that a new clinical commissioning consortia will replace the board of NHS Bristol, formerly known as the PCT.  The South West Strategic Health Authority will also be scrapped.  The new commissioning body will no longer be comprised solely of GPs, as proposed in the original Bill.  It will also have representatives of hospital doctors and nurses and will have a either a lay chair or deputy chair to ensure that there are no conflicts of interest when services are being commissioned.  The commissioners will also have to make their decisions in public.  This is a new level of transparency in the NHS and a welcome reform.  In addition the commissioners will be expected to operate within the same local boundary as social services, such as the boundary of Bristol City Council.

Public accountability will be further enhanced by the scrutiny of new Health and Well Being Boards, primarily consisting of local members of Bristol City Council.  A third level of accountability will be achieved by Healthwatch, which will replace the existing patient forums.  Healthwatch will be the main vehicle for providing patient feedback to the providers of healthcare, which in Bristol are mainly the two hospital trusts, University Hospitals (centred on the BRI and specialist hospitals) and North Bristol (Southmead and Frenchay) as well as Avon & Wiltshire Mental Health Trust.

The revised Bill thus has a new emphasis on local decision making, responsibility and accountability and it is hoped this will allow each area to progress at an appropriate pace towards the goal of a less bureaucratic but more innovative and responsive NHS.

The Coalition Government has listened and has brought forward reforms of the NHS that will enable clinically driven improvements.  The revised Bill will promote collaboration not competition and will introduce real local control and transparency.  I hope we can all now move forward and concentrate on tackling health inequalities and the conditions that really affect peoples’ lives.

21 Comments leave one →
  1. Rob permalink
    June 14, 2011 10:33 pm

    Why did you vote for the original bill?

    • Confused permalink
      June 15, 2011 8:09 am

      This is excellent news Stephen. However you may wish to contact the parliamentary authorities as they have clearly made a mistake and recorded you as voting for the bill at second reading. Given this is where the important principles of the bill are discussed and baring in mind your eloquently expressed oppositionhere, they must have made a mistake. Can you clarify?

  2. Patrick permalink
    June 15, 2011 8:59 am

    Why on earth did you ever support the original bill?

  3. June 15, 2011 10:01 am

    The Bill is still at its Committee Stage – that’s when amendments are made. The Second Reading vote is NOT a vote to approve the contents of the Bill, it is a vote to allow it to go to committee for detailed consideration. The vote giving approval to a Bill is the Third Reading, which comes AFTER the committee stage. I hope that clarifies the sequence of events.

    • Tom permalink
      June 15, 2011 4:25 pm

      Surely if in your words “the original Bill was not on the right lines” then you want to reject it not in your words “allow it to go to committee for detailed consideration”. Which is it, wrong in direction or needing detail tweaks?

    • Rob permalink
      June 15, 2011 5:06 pm

      That answer has zero credibility Stephen. I’m not sure you have yet grasped that what really annoys many people who voted for you are not your opinions, but that you continue to treat them like fools with answers like that.

      • June 17, 2011 10:43 pm

        Rob – so which part of the answer is incorrect?

      • Rob Davies permalink
        July 27, 2011 12:23 pm

        I refer the honourable gentleman to the answer given by Tom….

  4. Rob permalink
    June 19, 2011 9:51 pm

    The implication that you voted for the bill to pass to committee stage just so it could be considered further rather than as a coalition foot soldier doing your duty to keep the peace. Out of interest how did you vote on the issue at Lib Dem conference?

  5. David Brewer permalink
    July 8, 2011 9:35 am

    so sick of this bullshit. Agree with Rob.

  6. John James permalink
    July 13, 2011 11:03 pm

    Far from streamlining the NHS it seems there will be even more bureaucracy,- more chiefs and fewer Indians.
    Why is the NHS paying vast sums to rent Clinics, can’t that money be spent direcly within the NHS. Don’t tell me it gives me more choice, that is a red herring. If I commission a Surgeon within the NHS, I would be better served by that Surgeon within the service, the thought of having surgery sooner would not entice me to go to a Clinic. In my experience these Clinics poach patients from the NHS Hospitals without the knowledge of the original examining physician.

    • July 15, 2011 10:53 pm

      John – the contesability you refer to has been a feature of health care for several years now, introduced by the last Labour govt. The coalition govt’s reforms now call for collaberation rather than competition.

  7. Rob Davies permalink
    July 27, 2011 12:27 pm

    Now it would appear that you’ve not even read the bill…. http://www.telegraph.co.uk/health/healthadvice/maxpemberton/8655242/The-day-they-signed-the-death-warrant-for-the-NHS.html

    If you ever do finaly get round to reading it could you let us know if you still stand by your statement that “There will be no “cherry picking” of profitable services by the private sector and certainly no “privatisation”, which was never on the agenda but was the subject of much scaremongering”?

    • July 27, 2011 6:26 pm

      that article is a gross misrepresentation of the interview I had with the man from the Torygraph, which now has a history of sting operations on Lib Dem MPs. I explained to him the process for Bill consideration. I am not on the Bill Committee for the Health Bill, so like the other 620 or so MPs who are not on the Bill Committee, I haven’t and won’t be considering it line by line. That’s what the Bill Committee does, with my colleague John Pugh covering for the Lib Dems. As the Bill is a controversial one it has been the subject of several meetings of LIb Dem MPs where the sticking points have been discussed in great detail. These meetings have taken place frequently over the last 6 months. I gave Pemberton another example – the Finance Bill that implements the Budget. I was on that Bill Committee and so have been through it line by line. I would not expect my colleagues who were not on the committee to replicate this process. The process for consideration of Bills is so badly reported by the press that I’m not surprised there is ignorance or misunderstanding. Mr Pemberton is entitled to his views on the Bill but he should have left it at that, without giving the false impression that MPs neither know or care what is in the Bill.

  8. James g permalink
    July 27, 2011 8:16 pm

    It seems to me your position as mp requires you to put forward the views of your constituents – who are clearly in complete opposition of the bill. This has not been satisfactorily completed in this case, however this can be rectified: it’s not too late to listen and speak out to your colleagues.

    • July 27, 2011 8:25 pm

      James – the point of my article above was to show that concerns about the Bill, from my Bristol W constituents and many interest groups around the country had indeed been taken on board by me and my Lib Dem MP colleagues. That is why we debated it at our conference in March and why there have since been substantial changes. We listened, we debated among ourselves in Westminster and we have acted.

      But I would caution against “clearly in complete opposition” type comments. Most of the letters I received were about particular aspects of the Bill, which have been addressed. I doubt if people are opposed to more health service research programmes, or to a duty to narrow health inequalities or to have more collaberation between the NHS and social services…

      • James G permalink
        July 28, 2011 6:36 pm

        Dear Stephen,
        Thank you for taking the time to reply to my comment. Of course, any correspondence from constituents will reflect on particular aspects of the Bill. The problem is, these issues may well have been “addressed” but have not been dealt with adequately.

        1. Budget/tariff: the NHS tariffs include overheads, e.g. seniors/complex equipment for cases with complications. This money would be lost from the NHS under the current proposals (and line pockets of privateers), so a patient referred to an outside provider could end up needing care that is unavailable on the premises. Of course reducing patient throughput from hospitals also reduces the money available to them, which places the key constitutional aim of a nationally available service at risk: if departments close, the senior doctors (who are not required at “other providers'” facilities who simply provide low-level services) will simply not be there to treat patients – thus the standard of care is not only reduced, but lost. This effect is at a local level (shown in the example below) so goes against the core founding principal of a nationally available, uniform National Health Service.

        2. Consortia – the number of these has spiralled out of control, and is now far more than the number of PCT’s. This does not look like a reduction in beaurocracy.

        3. Cost – at £1million a day increase since the first proposals, this is infuriating.

        4. Known issues, such as complaints system, simple inefficiencies in paperwork at a ground level, specific benefits to patient care, etc. are not addressed at all.

        A good example is given in interview with Prof Steve Field here:
        http://www.guardian.co.uk/society/2011/may/13/andrew-lansley-nhs-reforms-unworkable.
        Quoted:
        “”The risk in going forward [with the bill] as it is, is [of] destabilising the NHS at a local level. It would lead to some hospitals not being able to continue as they are. If you were to say ‘we’re going to go out to competition for vascular surgery services’, University Hospital Birmingham wouldn’t be able to run their own trauma centre, for example, because you wouldn’t have the staff and the skills on site to do things and the volume of procedures needed to ensure clinical standards remain high.”

        UHB is one of England’s best-regarded hospitals and its trauma service, which treats injured military personnel from Afghanistan and Iraq, is widely admired.”

        We are counting on you as our MPs to safeguard our NHS – yes, reforms are necessary. These particular reforms are too costly, too top-down, and jeopardise service provision without any evidence to support them.

        Please, go ahead and quote any section of the reforms that disagrees with anything I have written there. Alternatively, raise these issues loudly and clearly, and support your constituents’ concerns further.

  9. July 28, 2011 9:30 pm

    James – thanks again. i will put these points to ministerial colleagues handling the Bill for comment. In the meantime – I’m not sure I get your point about number of consortia – they are intended to match the boundaries of social services authorities such as Bristol or Somerset. Most PCTs already match these boundaries.

  10. James G permalink
    July 30, 2011 12:56 pm

    Thank you very much. Actually since I have worked hard there to raise concerns with things you have said, I would like to add that before I read your response to Rob Davies above, I had no idea that a Bill so important as this was only actually read by a fraction of MP’s. Naturally I disapprove of this, but it is probably somewhat outside your remit? If there is somebody I should contact regarding that issue, I’d appreciate it if you could let me know.

    The comment re: consortia numbers is really related to a ‘clouding’ of information in the media lately regarding who will do what under the revised plans. It certainly appeared from Prof. Field’s recommendations that many more people and commissioning staff would be needed to ensure improvements in patient care, which contradicts the government’s proposal to reduce beaurocracy… To be perfectly honest that isn’t an issue I’ve looked deeply enough into but is concerning to see – along with the cost of this which has risen by £1million a day, which we can only assume is for staff (paperwork doesn’t suddenly cost that much!).

    One further cause for concern has just been announced in the media: variability of standards of GP practices. Currently they are run similar to how a private company is run: they are allocated a budget, and can decide what to do with it. This has caused a non-uniform service (contrary to the founding principles, anti-postcode lottery etc.). This gives further clout to the argument that choice does not lead to improved patient care.

  11. May 29, 2012 4:50 am

    So much good sense from so many respondents. The obticjeve is widely shared of a good hospital, reasonably close, in a national service sharing best practice’. Even to think of the service we all wish’ is to think of democratic expression. We may thank the Coalition proposal for raising the fundamental choice to be made between democracy and variants of human husbandry’. As a retired doctor, also a patient and a relative, I welcomed the promise of the Health and Social Care Bill 2011, at first sight the liberation’ of all to ensure equity’ and excellence’, within a reformed system of Health and Social Care, preserving the 1948 NHS principle of treatment free at the point of need’.Unfortunately, definition was lacking as to the meaning of principal terms:1. The liberation’ intended is for competition, in pursuit of profit, leaving quality to be defended by regulation’ rather than advanced by secure conscience and free communication.2. The promised equity’ in care will continue to be as far as might be deserved’, inequality of access left to be dictated by inequality of political power or insurance cover, poverty left as deserved and to be only palliated by state or private charity.3. The hoped-for excellence’, serving the top end of a market with unequal access, might easily be both exclusive and precarious in its isolation, and its impact on national statistics might be overwhelmed by a long tail of poorer performance, emulating the United States in value-for-money failure.Many have drawn attention to the downstream semantic deficiencies of the Bill and of the Listening exercise. We are invited to comment on four groups of questions, in areas sensibly to be addressed only alongside each other:1. With respect to the leading question, how can we best ensure that competition and patient choice drives NHS improvement’, we should rather be asking what steps must be taken to liberate inventiveness and care and funding as appropriate to democratic ambition?’ At present we can only guess at the dimensions of patient choice’ that in a democratic society might be thought worth the bureaucracy’: given equality in the market’ we might wish to choose our surgeon, priority in non-urgent procedures, the latest of room facilities, etc. In a democracy the essentials of health care would not be delivered in a levelled playing field’ for the material elevation of doctors or managers or share-holders. Even if, in a democratic society, global and sectional healthcare budgets were adequate, competition would play a part in the allocation of funds for individual training, for particular research projects, for service developments, for new sites, etc. Healthy competition would be on merit, for society, not tainted by fear or greed possessing concerned individuals. We do not have to choose between systems half-understood in America or Europe, or in recent party propositions: we can choose democratic liberation.2. With respect to the vital question how can we make the NHS properly accountable to the public, and make sure that patient involvement is at the heart of its decision making’, we might trust to luck (!), to political salesmanship (and luck!), to simple humanity (our care for the unfortunate, and luck!), to humanity expressed through inherited belief systems (injunctions to care, and luck!), or to the social contract offered by democracy. A democratic society might make mistakes, but it will tend to make its own luck’, to afford what is wanted and what is deserved, by the agreement and contribution of all. If we give up income inequality (to give and not to count the cost), and set a savings maximum at a reasonable level (my cup runneth over), we will free ourselves from fear and greed, enabling trust and liberating conscience. We need openness rather than transparency’ (having to watch out and seeing through’ each other’s dastardly schemes), and rational trust rather than accountability’ (having to defend or hide the hardly defensible). GP-led Commissioning, set-up out-with democracy, cannot emulate democracy: no mote than could PCTs working to equality agendas’ in recent years. Including the voices of other health professionals, patient representatives and politicians, and replicating much of past structural complexity, will quid soon be found essential in preserving or in re-creating the creaky NHS of today. The current proposal appears set up to allow a shake-down to a system of local private NHS-franchise-holders, sized for viability (comparable to PCTs), and like PCTs offering competition or co-operation according to population geography. Adopted as proposed, much bathwater and a few babies will no doubt be thrown out, much more of financial bureaucracy will no doubt be added, and the transition costs (financial and human) might alongside other looming problems within months or a very few years precipitate final demand for democracy.3. With respect to the linked questions, how can we ensure that advice and leadership from NHS staff themselves on improving services and tackling patient needs are at the heart of the health service’, and what more could we do to ensure that commissioners collaborate to fit around the lives of patients and carers, and the particular circumstances of certain conditions’, let there be freedom of movement of people towards worthwhile work, and freedom of voice to attract funding towards worthwhile work, no personal financial advantages and fears to corrupt, just the joy of the worthwhile and the ever better. In all of the scandals that over decades have continued to emerge, in our NHS’ as elsewhere, someone knew’ or had concerns. Our great need is for the liberation of all, making all representative of all. Only income equality can deliver the security required for universal freedom of conscience. The logic has to be faced every labourer treated as worthy of hire if we are to enjoy the fruits of democracy, an end to the rush to use up the Earth, a future of not hundreds but millions or billions of years.4. With respect to the question how can we make sure that NHS staff in the future have the right skills to meet changing patient needs’, the need is to respond to demand, and if possible anticipate both increase and decrease in demand, erring on the side of over-provision, trusting in the good sense of trainers and trainees, all aiming for careers of service’ rather than careers of shelter or financial advantage’. There is scope for far more cross-fertilisation of ideas and practices, with earlier recognition of need to adapt, or focus more narrowly, or move on, unimpeded by personal and family financial considerations. Strategic planning will always be difficult, more so with commercial secrecy. Past arrangements were poor, the current I am not involved with, the proposed will have to be proved in a context of chaos, I would guess leading to greater variation in quality, increased emigration, and even greater reliance on imported labour with attendant difficulties of integration here and of loss from countries of origin. Until we have genuine democratic government all free to represent all we can only guess what systems of care and investment a democratic society would choose. Until we have such a democratic context, it must be the responsibility of pro-democratic governments both to lead towards democracy and to frame legislation as far as possible as if for a democratic society.We live in a society that has worked and fought for democracy. If a democratic future is wished, then each generation must educate the next to that end. In the spirit of Benjamin Disraeli, truly to educate our masters’ we must show willingness to educate ourselves. As a start we need to have a shared language, recognising ambiguities and clarifying central intents in the use of words, aiming for sharable understanding based on a logical sequence of value choices. I would commend the prime choices of faith in the worth of caring, and trust in the wisdom of genuine democracy, not to officiously strive’ but to give care to others’ as we would wish for ourselves.The Coalition has to deal with the world of today, but we all today could affirm our choice for a democratic future, taking account of life’s trials and seeking to reform the NHS as if for all, for patients and relatives and staff and society as a whole.

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