| Previous Section | Back to Table of Contents | Lords Hansard Home Page |
We have demonstrated that it is possible to turn around poor performance in NHS foundation trusts. Only once, with Bradford Teaching Hospitals NHS Foundation Trust, has it been necessary to use formal powers of intervention to engineer a turnaround. However, Monitor’s compliance regime has identified and led to the resolution of poor financial or service performance on a further 10 occasions. The most significant was the fast and effective turnaround of UCLH, where a £36 million loss will became a small surplus in 2007-08. I pay tribute to the members of the board of that trust for the work they have done, but we did a good deal to support them.
I am very pleased to see the Government ending the practice of year-end brokerage and moving to a system of repayable loans; that is, ending the detested RAB regime—the system of resource accounting and budgeting imposed in 2001, a double-deficit programme that was so detested—and moving to a loans-based capital regime with access based on affordability. This is in line with the Audit Commission’s recommendations arising from its review last year. We support that. These changes should help to drive improved financial performance in NHS trusts. However, the full benefits will be delivered only as we move more trusts to foundation trust status.
I return to where I began; that is to patient care. Focus on finance does not come at the expense of quality. Indeed, organisations that have proved themselves competent in financial management are also competent at getting to grips with clinical governance issues within their trust. They are simply better managers and 68 per cent of NHS foundation trusts are rated excellent or good compared with only 50 per cent for NHS trusts.
I have gone banging on about the Monitor regime because the process of becoming an FT is very rigorous and only those fit for purpose get through. The process leads to better governance and financial management. We take corporate boards and their governance capacity very seriously through our board-to-board meetings. As a result of the process, East Somerset NHS Trust recently completely reshaped its capital plans and South Devon Healthcare NHS Foundation Trust dropped its over-ambitious PFI scheme to go for an incremental
26 Apr 2007 : Column 779
The process has also led to NEDs with greater financial experience being recruited than was the case in 2004, which is crucial for support. So I am optimistic that if the Government stick with their intention to devolve care to autonomous providers, add the spice of competition generated by the independent sector and press on with their personal choice agenda for patients and their families, NHS finances will get healthier and healthier. That is the way forward, rather than carping on about the endless inadequacies of the NHS accounting regime.
12.24 pm
Baroness Shephard of Northwold: My Lords, I congratulate my noble friend Lord James of Blackheath on so ably introducing this debate. The Minister will confirm the diligence and zeal with which he has pursued detailed information about the funding of the NHS. The fact that his researches have, finally, led him to describe the NHS accounting system as critically as he did today should be a matter of concern to all of us.
It is beyond doubt that more resources are going into the NHS. I am totally at one with the noble Lord, Lord Haskel, on that. The Government have, rightly, frequently been congratulated in this House on that fact and, indeed, on the number of initiatives they have introduced to improve patient care.
At least as important as the amount going into the NHS is the way in which the money is spent and the quality of ministerial decision-making. Even more important—and I really have to say this—is that without transparency in the use of resources there can be no democratic accountability. That is one of the really grave criticisms highlighted today by my noble friend. I hope, as do we all, that the Minister, who is rightly well respected and admired in this House, will be able to answer clearly my noble friend’s detailed questions—although possibly not all of them—when he concludes the debate.
The lack of financial transparency in some parts of the NHS causes the public to question whether the Government’s claims of increased funding are true. That is why transparency matters. Certainly, more money has gone into medical staffing. However, it seems also to be the case—and this is widely the public perception—that GPs and consultants are being paid a great deal more for doing less. It is also the perception that that has come as a surprise to Ministers. Of course there is public support for our doctors to be well paid, but there is this perception that there are cuts in GP services as a result of the pay and structural changes. That leads to, at least, puzzlement that taxes appear to have gone up to provide less service.
While we must accept, as it is the case, that more money is going into medical staffing, what should we make of the extraordinary saga of MMC; the Modernising Medical Careers initiative? That has been described by the Royal College of Physicians as:
26 Apr 2007 : Column 780
How could the Government have created a situation where, as Michael Jack pointed out last week in another place, there is a misfit between the 30,000 junior doctors aspiring to reach higher posts—in other words, people who have been trained—and the 22,000 job opportunities that exist for them? Are the Government now attempting to reallocate the surplus of doctors to Voluntary Service Overseas? Are our precious resources being devoted to this attempt? It is hard to believe that that could be so. It is certainly true that you could not overstate the effect the situation has had on doctors’ morale, not to mention their respect for ministerial planning.
However, I assume that there was also some sort of financial effect. What has it cost? What services may have to suffer as a result? I am sure that the noble Lord will be able to tell us something about that in his concluding remarks today. Perhaps he will give us a bit of comfort because everybody is concerned.
I have at least twice in this House raised the contrast between the reality of people’s experience of the NHS at local level and claims sometimes made by the Government. I make no excuse for doing so again today since we are debating the use of resources in the NHS. As I said earlier, what matters to people is not only the amount of money going into the NHS, but also how it is spent. Indeed, in the light of the points made by my noble friend, I raise the clarity or otherwise of the accounts—in other words; where is the money going?
I again raise an example from Norfolk where people, as elsewhere in the country, know that more money is going into the NHS. The people in Norfolk have been told that the Norfolk PCT is in debt to the tune of £50 million. For that reason, cuts in services have to be made across the board. I need hardly add that the people of Norfolk do not feel responsible for this debt of £50 million. We cannot establish who ran up the debt or who should be held responsible—we apparently cannot be told. There is no accountability. Of course, in the light of what my noble friend said, I wonder whether there is a debt; could it be an accounting devise? We do not know. But whether or not the debt is real, the effects of meeting it most certainly are. They are causing universal fury across the whole community. Because of the real or imagined debt, all nine of Norfolk's community hospitals are being considered for closure or cuts in services.
The Minister will know how unpopular such proposals are, not least because his ministerial colleague, Ivan Lewis, has been demonstrating against them in his constituency. Ivan Lewis has been joined by a clutch of other Ministers, not least Jacqui Smith, the Government Chief Whip in another place, and Hazel Blears, the chairman of the Labour Party, in demonstrating against the changes in their constituencies. Part of the reason for people’s fury and resentment at such changes is that they are being implemented and local services reduced while they are being told that the NHS is improving. People find it hard to equate their experience with what they are
26 Apr 2007 : Column 781
I accept that the structures described by the noble Baroness, Lady Murphy, may help, because there will seem to be more local accountability and, perhaps, more local flexibility. If that is the way that things are to go, there will be a greater feeling of ownership locally. That will certainly help.
It has not gone unnoticed in Norfolk that the PCT has spent thousands of pounds on consultation. Local people have themselves organised huge public meetings. There have been petitions to Downing Street, delegations to Ministers, and so on. The current proposals have resulted in universal ironic hilarity. They suggest that the whole of the western half of the county of Norfolk—the half which, according to government definitions, has the largest number of deprived wards—is to be left with no community beds at all. It has not been possible to explain to the PCT that such a proposal will not do and that it sits ill with assertions from the centre that community-based services are to be developed and brought closer to the people. It has been received with consternation by the county council, which is hard pressed to provide even exiguous domiciliary services already and knows that it will bear the brunt of the cuts.
That seems to be curiously divorced from the announcement a year ago that £750 million of extra funding was to be devoted to community hospitals. The Minister kindly answered me when I last raised this in the House. What is a puzzle is that the Norfolk PCT, which is in deficit, possibly to the tune of £50 million, made no application to the fund of £750 million. Why not? Did it not know about the deficit at the time? Perhaps it did not. More sinisterly, perhaps it had already made up its mind on the future of those community hospitals—in which case the consultation is a sham and the money devoted to it a waste of resources. Who can say?
I am sad today to appear to be attacking the Minister. I greatly respect him, his knowledge and the way that he tackles his job—which, in all conscience, is enormously difficult. Complexity in NHS funding certainly did not start with him. All of us know that and we admire what he tries to do, but I cannot believe that he can be happy about what is being presented locally as government policy—that these cuts have to be made and these hospitals closed because the Government say so. We understand that the finances are complex, but I feel that the Minister will understand our concern that that complexity may be denying the Government legitimate credit for what they are attempting to do. I hope that he will be able to reassure us later.
12.33 pm
Lord Bradley: My Lords, I also congratulate the noble Lord, Lord James, on his opening speech. I tried very carefully to follow his audit trail through accounting in the National Health Service—not totally successfully, but I certainly heard the word Manchester used. I shall concentrate my short remarks on the city of Manchester and on what has been achieved in the past 10 years.
26 Apr 2007 : Column 782
Although I entirely agree that there needs to be transparent accountability for expenditure in the National Health Service, the improvements in the quality of care in the city and city region of Manchester have been dramatic during the past 10 years. Those dramatic improvements have been based on the considerable investment, both capital and revenue, achieved under this Government. In the city, we now have a much clearer pathway, as a result of that investment, to high-quality primary and community care; clear routes into secondary care with significant investment in our district general hospitals; and further massive investment in tertiary services, which enable the highest quality specialist care to be provided in central Manchester and other specialist hospitals.
That is against the background of huge health problems in urban centres such as Manchester, huge inequalities in health and huge problems with late referral, because people in urban centres do not always recognise their health problems. That means that investment is needed not only in hospital services but in primary community services to ensure that health problems are detected at the earliest opportunity.
I should declare an interest both as a non-executive director of a hospital trust, now a foundation hospital, Christie Hospital, a subject to which I shall return, and as non-executive chair of a local improvement finance trust—LIFT—company, which is responsible for the development of health centres, clinics and service centres for Manchester, Salford and Trafford. I start there because where we are dealing with areas of high deprivation and poor health, investment in primary services is crucial.
During the past two or three years, at least 13 new health centres have been developed and built through the LIFT company, not only to provide high-quality GP practices in those centres but to enable a much wider range of screening and community services to be developed to ensure that we start to tackle inequalities of health. That is in partnership with local authorities. Although we may need clear accountability within the National Health Service, we must work in partnership with other providers, especially local authorities. With the reconfiguration of primary care trusts and consultation with local authorities, it will be crucial to have a strategic plan that drills down to the real needs of local communities.
In south Manchester, for example, there has been huge investment in the South Manchester University Hospital and performance has been dramatically improved in recent years. Although statistics and targets are not everyone’s preferred method of assessing the success of the National Health Service, they give clear indicators of progress. They also enable the organisation to see its direction of travel. To pick out one or two statistics in south Manchester, 97 per cent of all elective patients were able to book their appointments at a time convenient to them. That could not happen without the investment in our hospitals. Also, 97.8 per cent of patients were seen, treated and discharged from accident and emergency
26 Apr 2007 : Column 783
Turning to central Manchester, there has again been huge investment: a £600 million investment in a new hospital, with a new children’s hospital under way as we speak and a £1 billion investment along the Oxford Road corridor linking the hospital more closely to the university—I should obviously declare an interest as an employee of the university. At the end of March 2006, no patient in central Manchester waited longer than 13 weeks for a GP out-patient appointment. Thirteen weeks is too long but is still a significant improvement on previous waiting times. No patient waited longer than six months for in-patient or day-case treatment—again, a huge improvement and, again, 98 per cent of all A&E attendees were seen within four hours. This must be seen against a backdrop of a continuing year-on-year increase in the demand for these services; they cannot be seen in isolation from the healthcare needs of the local population.
In central Manchester, the trust performed outstandingly well in cancer treatment. At the financial year-end in March 2006, 100 per cent of patients received their treatment in 31 days after a diagnosis of cancer, against a national target of 98 per cent. In addition, 97 per cent of patients received their first treatment within 62 days of a first referral from a GP, against a national target of 95 per cent.
I am proud that this Government have highlighted cancer as a key area for investment, because one in three people in this country is diagnosed with cancer, and one in four people actually dies from it. Unless we look at the investment in that area, we will not tackle one of the real killers in this country. Christie Hospital, of which I am a non-executive director, as I said, achieved foundation status on 1 April. I strongly agree with the noble Baroness, Lady Murphy, about the role of monitoring in that process. The process by which the hospital trust had to comply with the requirements, particularly the accounting and other financial requirements, which the noble Lord, Lord James, identified, was extremely hard and rigorous.
The way in which the hospital’s executive team moved the hospital forward so that it could comply with foundation-trust status should be a model for all hospitals. That status would be achieved at different speeds, but the model ensures the rigorous analysis of resources, accounting and governance in those hospitals to achieve real improvements, not to make profit but to make surpluses that can be reinvested in patient care in such hospitals. That is the crucial point.
In the past financial year, Christie Hospital managed to create a surplus of £3.6 million, all of which will go back into improving clinical care in the hospital for the benefit of patients. The monitoring process should be commended for that. The surplus will enable Christie Hospital to expand its services in radiotherapy and chemotherapy, and to move services away from one site into the local community so that they are much more accessible to patients. It will also
26 Apr 2007 : Column 784
I hope that the Minister will be able comment on the 62-day target for cancer treatment from first point through to referral and treatment in a specialist centre such as Christie Hospital. Ninety-six per cent of patients are treated within 31 days of referral. The problem arises downstream in the 31 days that it should take from initial GP referral to the patient’s arrival at Christie Hospital.
The hospital does not receive patients directly from GPs; it receives them from district general hospitals. There is a difficulty if those district hospitals do not identify the cancer needs of that patient in a timely way to enable Christie to comply with the 62-day target. I know that work is being done with the Healthcare Commission to look at this issue, but I hope that the Minister will recognise the complicated pathways from first referral by the GP to treatment in a specialist centre, and that this will be carefully monitored to analyse whether hospitals such as Christie are performing to the high standards to which we clearly believe we are.
All these improvements in healthcare in a city such as Manchester could not have been achieved without the huge investment that has been made or without the continuing dedication of the staff and management of those hospitals to use those resources with rigour. I believe, as I have stated, that that rigour is now being applied to the National Health Service through the monitoring process for the benefit of patients. Such investment must continue year on year, otherwise those improvements will not be maintained. The direction of travel that has been achieved in recent years, together with the investment—both revenue and capital—has enabled a higher quality of healthcare service to be created in this country, and patients appreciate those improvements.
12.45 pm
Lord Fowler: My Lords, it is a great pleasure to follow the noble Lord, with his Sutton Coldfield roots, although he spoke almost exclusively about Manchester on this occasion. I congratulate my noble friend Lord James on leading the debate and on his speech. We look forward with delight to hearing the detailed reply that we know the Minister will give.
I shall deal with the issue a little more generally. My noble friend reminds us that resources in the health service are rationed. However much you spend, you will never have enough instantly to meet public need. As Enoch Powell once put it, you have infinite demand meeting finite resources. That is why my noble friend is so right that the use of resources is of the essence. That is why every pound must be made to count. Doubtless, the Minister will remind us, as we have been reminded already, of the increased resources that are being devoted to health. I am glad that, in the past 25 years, the economy has strengthened so that that can happen. The Government are on much less firm ground on the use
26 Apr 2007 : Column 785
I want to pursue another aspect of resource management. If the Government decide that a particular service in the National Health Service is a priority and deserves extra resources, clearly those resources should follow that decision, otherwise it is an entirely pointless exercise involving the kind of funny money about which my noble friend Lord James has been speaking. The Government said, with good reason, that sexual health services and HIV were a priority for 2006. Here, I declare an interest as a trustee of the Terrence Higgins Trust. Sadly, there is no doubt that the position has deteriorated over the lifetime of the Government. Some 70,000 people are now living with HIV and, on present trends, that number will go through the 100,000 mark in three or perhaps four years’ time. We have seen a threefold increase in the number of people accessing HIV treatment and care services, and new diagnoses have increased by 165 per cent over the same period. Where our position was once the best in western Europe, it is now one of the worst.
The Health Protection Agency identifies HIV as one of the most serious infectious diseases facing the UK. However, we are not only dealing with HIV but are confronted by the danger, the risk and the suffering caused by increases in other sexual diseases. The latest figures show that there were 110,000 new diagnoses of chlamydia in 2005—an increase of 125 per cent since 1998. Using the same 1998 base, there have also been big increases in both gonorrhoea and syphilis. So the story continues. The result is that the sexual health clinics and GUM clinics are under severe pressure. The premises are often outdated and crowded, and we know from a recent report that the consultants on the ground are often frustrated by the lack of priority that is being given to this area.
| Next Section | Back to Table of Contents | Lords Hansard Home Page |