Editor's blog Thursday 26 May 2011: Text of Labour shadow health secretary John Healey's RSM speech

Thank you for allowing me to join you and mark this last week of the Government’s so-called “pause to listen” on their NHS reorganisation. I know that your Society deals with policy, rather than politics. And that you’re expertise lies in professional standards, not political argument.

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Click here for details of 'Lansley: the NHS is not a mobile phone; I am not Henry V', via subscription-based Health Policy Intelligence.

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But understanding the Prime Minister’s “pause”, and the pressure and potential for changes in health policy means understanding the politics too.

The Society is an renowned centre for learning and research. And I realise you have not made direct policy submissions to Government. But you have made important contributions to the current health care debate indirectly through the studies you’ve published recently on the risks in the Government’s commissioning plans to financial stability and to mental health.

I fear the Prime Minister’s response to this “pause” will be shaped more by the politics of his divided coalition than by the strength of the health policy case and evidence.

So – now 6 months into this job of Labour’s shadow health secretary – I’d like today to offer:
... my assessment of the underlying politics of the Government’s NHS plans
... my analysis of the scarcely spoken but fundamental policy changes at the heart of the health bill; and
... my Labour amendments to the legislation that we are tabling today.

This “pause” is unprecedented. The health bill is almost through the House of Commons but the Prime Minister has told his health secretary to stop what he’s doing while he asks anyone and everyone else what he should be doing instead.

In the 9 weeks’ “pause” the Government is doing what it should have been doing for the 9 months before – looking at the evidence of what works, listening hard to those who know the NHS and learning from the views they get.

This is not rocket science. It’s simply good government and it’s good politics. Both have been totally absent in the health department since last May.

If the Prime Minister’s “pause” is unprecedented, it was also forced upon him.

He reads the polls which show public concern about the NHS at a 3-year high and rising rapidly. And he knows the growing crisis of confidence over his Government’s  handling of the NHS.

He launched the “pause” to clear up confusion and settle concerns. But this has backfired. Criticism and confusion have grown during the pause period.

Even the chair of the Prime Minister’s Future Forum “listening panel”, Dr Steve Field, has said the NHS changes are “unworkable” and could “destroy key services”.

Our NHS deserves better. Nearly 5 million NHS patients each week and 1.4 million NHS staff deserve better from the Government.

The test for the listening panel is how far and how faithfully their report reflects the fundamental criticisms of the Government’s NHS plans.

David Cameron is a PR man who was looking for a PR answer. As Prime Minister, he must accept the problem is not the presentation of his NHS plans but the full-scale free-market ideology behind them. This ideology is totally at odds with the ethos of the NHS and the essential way the NHS works.

The test for the Prime Minister is whether he now makes the changes required to honour the promises he made to protect NHS and guarantee patients will see health care get better not worse. Whether he makes the changes required to safeguard the NHS and help it to meet the challenges of the future.

The Deputy Prime Minister is also making a speech on the “pause” today. After the Lib Dem’s local elections disaster, Nick Clegg’s concern is to save his party not safeguard the NHS.

He is up to his neck in David Cameron’s NHS plans. He has backed them every step of the way for 12 months.

They made and broke together the Coalition Agreement promise “to stop top-down reorganisations”.

They co-signed the foreword to the NHS white paper in July.

His Lib Dem MPs have backed the bill in Parliament at every stage so far.

And in committee it was his Lib Dem health minister who led rejection of Labour’s amendments to make the changes Clegg now claims he wants.

But for all Clegg’s bluster, he’s not setting tough enough tests for the changes the Prime Minister must make to his NHS plans. He’s selling out on the safeguards needed to protect the NHS for the future.

The risk is the Prime Minister decides on a political fix to deal with divisions in his Government not the dangers to our NHS.

Whatever he decides to do with his NHS plans, this first year has raised serious questions about the Prime Minster and his Government’s judgement, competence, values and integrity.

These questions are important because they raise doubts about the trust that people can place in the Tories on the NHS that will reach well beyond the “pause” period.

Judgment
Forcing through the biggest reorganisation in NHS history when it is facing the tightest financial squeeze for 50 years runs huge risks and comes at a high cost.

The health select committee, public accounts committee, King’s Fund, NHS Confederation and others have all questioned the wisdom of doing so.

Nearly £2 billion promised for patient care has been set aside to cover the costs of this internal reorganisation in this year alone.

Removing and reinventing the internal infrastructure for commissioning, provision and regulation all at the same time, while simultaneously trying to push through big efficiency savings, is profoundly reckless.

Competence
The principles of good public policy are consult first, legislate second and implement third.

This proper order has been reversed with the NHS reorganisation.

Furthermore, by omitting this huge reorganisation from the Conservative manifesto, and by emphatically ruling it out in the Coalition Agreement, David Cameron has failed to establish a democratic mandate for the health bill, either from the Election or the Coalition Agreement.

Values
David Cameron tries to make “I love the NHS” his signature tune. But there’s a big gap between what he’s saying and what he’s doing. You have to look beyond the content of his speeches to the content of the health bill to see the true Tory purpose.

Because this bill ...
... breaks up the National Health Service
... removes the principles of public and parliamentary accountability for the NHS
... turns the NHS into a full-scale free-market.

What the Tories did with public utilities in the 1980s, they’re doing now with public services.

These are arguments that Labour – and only Labour – have been making from the start. And it is why I have led the outright opposition to the health bill changes from the outset.

The day after the health bill was published I warned in my Kings Fund speech that these are the wrong reforms, for the wrong reasons at the wrong time.

In more recent months doctors, nurses, patients groups, NHS experts, the health select committee, Peers on all sides of the House of Lords and finally even Liberal Democrats have raised similar concerns

Integrity
More serious still are questions over David Cameron’s integrity on the NHS.

The roots of the Conservative health plans go back to the 1990s when Andrew Lansley worked as a civil servant on telecoms deregulation. Soon after he first got the shadow health job in 2005, he set out a detailed policy speech in which he said that “maximising competition” is the “first guiding principle of NHS reform”.

As he told The Sunday Times two weeks ago, “David and I go back 20 years and every step of the way we’ve worked together on this”.

But in the run-up to the Election David Cameron didn’t tell people about his plans. Indeed he made a point of promising NOT to reorganise the NHS, telling the Royal College of Nursing “There will be no more of those pointless reorganisations that aim for change but instead bring chaos”.

He was not straight with people before the election. And he has not been straight with people since.

As he tried to construct a case for changes, the BMA’s first resolution at its first special meeting for 20 years “deplored the government’s use of misleading and inaccurate information to denigrate the NHS”.  

As he tried to deny the fundamental changes in his NHS plans, he talked of GP commissioning but not about competition, with 5 clauses in the health bill setting up GP commissioning consortia and 85 setting up the NHS as a full-blown market.

As his “pause to listen” ends, my message to the Prime Minister is this:
.... sort out the mess you’ve made of the NHS so far

... start being straight about the far-reaching ideological revolution in your health bill

... show you mean what you said when you promised to “protect the NHS”

... so scrap the bill as it stands, and make the fundamental changes needed to safeguard the NHS for the future.

Analysis of the fundamental changes in NHS policy
Let’s remind ourselves the concerns that professionals, patients and the public have raised are not just about the details but about the fundamentals.

As the King’s Fund has made clear, the changes are “more revolutionary than evolutionary” and “the biggest upheaval in the health service, probably since its inception”.

Clare Gerada, Chair of the Royal College of GPs has said, the Bill will “cause irreparable damage to the core values of the NHS”

I spoke at a public meeting in Hornsey and Wood Green this week. The title asked: “Will the government’s health bill change the NHS as we know it?”. The health bill won’t just change the NHS as we know it, the bill will end the NHS as we know it.

It breaks up the NHS, both nationally and locally.

It breaks the principles of accountability to patients and the public.

It breaks the NHS as a public service by turning it into a full-scale market exposed to and driven by the full force of competition law.

Breaking up the NHS service
Breaking up the national NHS service - The very first clause of David Cameron’s Bill breaks a 63 year consensus by removing the Secretary of State’s duty to provide a comprehensive national health service.

The Secretary of State of an elected government, answerable to the people and to Parliament, will no longer be responsible for:
- delivering a comprehensive health service
- defining the scope of health service entitlements
- deciding whether to levy top-up charges for other health care services.  
Instead, these powers and responsibilities will be passed off to several hundred local commissioning consortia and a new national quango, all with totally inadequate public accountability.

This is part of a coherent, consistent and comprehensive policy.

National waiting time targets – the guarantee for patients that they’ll be seen and treated promptly – have been scrapped.

NICE decisions on what drugs and treatments patients everywhere can expect on the NHS no longer be binding on commissioners.

From national conditions of service to career paths and education, national workforce responsibilities will be abandoned to local market decisions.

Patients will see greater variation and inequality in services. Patients will increasingly see a postcode lottery in health care.

Breaking up the NHS local service
The health bill brings to an end a national service but it also breaks up rather than integrates local service planning and provision.

Primary care trusts (PCTs) have their flaws but they have the duty to plan and commission for the health needs of everyone in the area – in prevention, public health, health protection, primary care, secondary care and specialist care.

These commissioning duties – all done by one body now will in future be done by at least five ...local councils, GP consortia, consortia clusters, the national commissioning board and its regional arms.

To borrow a phrase from David Cameron, an “alphabetti spaghetti” of new quangos.

As charities like Asthma UK have warned: “where the commissioning of whole pathways of care for some conditions will fall under the remits of public health, the NHS Commissioning Board and GP consortia, this risks the fragmentation of service provision.”

This worry is shared by many who care for vulnerable patients. I heard last week on a visit to Bristol that the local Samaritans are deeply concerned at this local fragmentation for people at risk of suicide.

Breaking public accountability
The Bill breaks the proper public openness and accountability of the NHS, there for all of us and funded by all of us.
- The  Secretary of State – no longer answerable to Parliament or the public for the delivery of a national service
- Commissioning consortia –with no obligation to meet in public, publish papers or disclose decisions
- Consortia with no patient voice, no nursing voice, no clinical hospital voice – no requirement even for GPs to run them and scope to outsource in full the job of commissioning to private companies
- No independent expert public health agency able to speak truth to power and protect the public
- Hospitals with no obligation to meet in public or consult the public on closing services, unless they have special protection by “designation”
Eight leading health charities, representing millions of patients from Alzheimer’s to Diabetes, have demanded that “If the new NHS is to properly serve patients and the public, this democratic deficit must be addressed and the voices of patients heard by those making crucial decisions affecting their lives.“

So much for the slogan: “no decision about me without me”.

Breaking the NHS as public service to set up a health market

People have asked, why the huge reorganisation? Why legislation more than 3 times longer than the Act that first set up the NHS?

The government’s general aims – a stronger role for clinicians in commissioning care, more involvement of patients, less bureaucracy and greater priority on improving the results for patients – could largely be achieved without the health bill and done by the evolution of the current system.

The legislation is needed to pursue the revolution of the NHS into a full-scale market, modelled on the privatised utilities and driven by the powers of a competition regulator and the force of competition law.
The Bill:
- Abolishes public service NHS hospitals, making Foundation Trusts commercial bodies
- Axes any cap on NHS hospitals treating private patients
- Allows hospitals to close services without public consultation  
- Makes hospitals going bust subject to commercial insolvency law, with no system of help for those in trouble.
- Sets up a competition regulator to enforce the Competition Act in the NHS.

.... By creating a regulator with a duty to promote and enforce competition.
.... By setting up NHS hospitals as fully independent economic undertakings, operating in an open market.
... By requiring ‘any willing provider’ to be the guiding principle for all NHS-funded services.
... the NHS is fundamentally changed into a free market.

Most important of all, the set of changes in part 3 of the health bill remove the present protection the NHS has as a public service from the full force of UK and EU competition law.
The remit of Monitor as the new competition regulator must change from the duty to promote competition to the duty to promote integration.

But this is necessary but not sufficient to safeguard the NHS.

Without dropping the other changes in part 3 of the bill, we will lose the protection the NHS has as a public service.

This means planning, costing, commissioning, coordinating services – even essential discussions between providers or with commissioners about who can best provide a service, how can services be better integrated for patients or what brings best value for money – risk being judged as anticompetitive, collusive, price-fixing and illegal ... if looked at through the lens of competition law.

The health bill as it stands will unleash this beast which can’t be controlled or put back in its cage.

There has been some attempt to deny this by Government so let me be clear .... The bill will require Monitor to enforce the Competition Act. This Act technically covers the NHS and has done since 1988 but the Office for Fair Trading have never used it in the NHS because it has always been a publicly managed system.

That will change because of the health bill. It means the ability to plan properly, commission confidently and coordinate services effectively will always be under the cloud of a legal challenge.

It means in future that many of the most important decisions about who provides what services in our health system may not be taken by GPs or NHS managers or politicians ... but by lawyers in the competition regulator and judges in the competition courts of London and Luxembourg.

There is a certainly a role for competition in the NHS. But we get the best for patients from competition when this is properly planned, managed and accountable as part of the coordinated improvement of services.

This will become impossible if competition law has the last word.

In all areas of care, we need to focus on what is right for patients and not on competition for its own sake.  

For long term conditions – responsible for three-quarters of health spending – healthcare needs to be well integrated. And competition means fragmentation.

For acute care, a full range of services needs to be well connected. And competition means cherry picking.

Trauma care, for instance, requires emergency care, anaesthesia, radiography, orthopaedic, vascular, cardiothoracic, neuro and general surgery, specialist nursing, therapies, intensive care and long term rehabilitation.

As Steve Field himself has admitted, forcing competition into any one of these services could undermine the world class trauma care provided for injured soldiers  at University Hospital Birmingham.

But with a relentless focus on what is right for patients, as a Labour government we began to transform services through strategic clinical leadership, planning and collaboration.

We are starting to see those results in this city, where improvements were kick-started by Ara Darzi’s review of London healthcare.

London had the worst record on stroke care. Now stroke victims in London now have better access to life-saving treatment than any other major city in the world. Saving hundreds of lives, thousands days for patients in hospital beds and millions of pounds for the NHS.  

As Lucy Grothier from the South London Cardiac and Stroke Network has said: “This is a great example of how collaboration provides patients with the best care possible.”

Patients’ charities and specialists are rightly worried by the risk to such progress with the break-up of the NHS and with competition rather than collaboration as the driving force at its heart.

Amendments essential to the NHS bill

Today the BMA has warned the health Bill represents an “enormous risk” to NHS finances and to patient care.

Yesterday, the NHS Confederation told the Government that the “current reforms are not sufficiently focused on the big problems the NHS faces.”

These are important messages and the Prime Minister should listen.  

Like the NHS Confederation and so many others, I know the NHS needs to change. Ed Miliband made the case for NHS reform very strongly last month.
Labour is – and always has been – both the party of the NHS, and of NHS reform.
Our recent reforms strengthened accountability to patients, responded to changing needs, and focused on improving the quality of services for patients.
David Cameron makes the case for change. But he has made the wrong diagnosis and written the wrong prescription in his NHS Bill.

This is a bad bill, based on flawed ideology.

The Prime Minister must drop the bill as it stands, and fundamentally change his NHS plans.

Yesterday I tabled a recommittal motion for the Health Bill to go back to square one for fresh scrutiny in the Commons.

This is a first in nearly a decade.

And I hope the Government will accept the constitutional case and support our Labour  motion.
Today, I will table and publish the amendments that we think are required as a minimum, to protect the health service and allow clinicians and patients to meet the challenges that the NHS faces today.

These are all arguments and amendments that Labour has been pressing from the start ... amendments that have been rejected by the Government so far.

A total of 40 amendments, over 14 pages ...

... to safeguard the “N” in the NHS
... to strengthen accountability to the public and to Parliament for vital decisions about services and spending £80 billion of taxpayers’ money
... to stop the government making our NHS into a free market.

Conclusion
David Cameron made another “I love the NHS” speech last week.

He pledged ... no privatisation; no cherrypicking from private providers; no new charges for healthcare services; no competition for its own sake.

But this is exactly what his NHS plans and legislation are designed to do.

If he means what he says; if he means to keep these latest NHS promises, he must drop his health bill and fundamentally rewrite his plans.  

If he won’t, then people will be right to conclude that they can’t trust the Tories with our NHS.