Pugh on the Health & Social Care Bill

• [May 10] John Pugh : THIS is déjà vu. In the last Parliament, it seemed like every other Opposition day debate was a health debate, normally called by the Secretary of State as the then Opposition spokesman. I trust that his enthusiasm for these debates is undimmed, although given that he has left us, possibly it is.

The Opposition allege that the Bill prepares the ground for the complete privatisation and fragmentation of the NHS through the introduction of an open market, pricing and competition regulation and the general disengagement of Government. However, the often very pained response of Ministers-this was certainly true in the Bill Committee-is that they are building and improving on previous policy, linking clinical decision making to cost control and adding a dimension of accountability that has not existed hitherto. All those statements are true. I noticed that in the Bill Committee, Ministers talked all the time about "refracting mirrors", "Opposition fantasies" and "deliberate distortions". In turn, the Opposition talk of "hidden agendas".

On reflection, I have come to the conclusion that there has to be an explanation for this strange phenomenon, this persistent conflict between interpretations of the same legislation, this clear non-meeting of minds.

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Grahame Morris (Easington, Labour: Will the hon. Gentleman give way?

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John Pugh : I was just about to give the answer, but I will give way.

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Grahame Morris (Easington, Labour: Is there not a simple solution? It is the Government's Bill, so why did they not explicitly rule out price competition in the Bill?

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John Pugh : I have a different explanation, which is that both interpretations can be sustained by a reading of the Bill. It is a kind of Jekyll-and-Hyde thing. I have a vision of the Bill being drafted during the day by a sane, pragmatic Dr Jekyll-like Minister, but during the night some rabid-eyed Mr Hyde with right-wing ideology breaks into Richmond House and changes many of the sentences. That is the only way I can explain the fact that the explanatory notes to the Bill provided in Committee explained very little.

The House might know that I am a long-term critic of the Bill and the White Paper before it. At the annual Liberal Democrat conference in October, I and the Minister of State, Department of Health, my hon. Friend Paul Burstow went around with a double act on the Bill-him for, me against. This is not, therefore, as Grahame M. Morris might think, a hissy fit following poor election results. Like nearly everyone in the House, I do not disagree with the Bill's objectives: more clinical involvement, less bureaucracy and more local accountability. Like everyone else, I am concerned not about its objectives, but about its likely effects. I have met no one who takes issue with the Bill's avowed intentions, but I have met many who dread its consequences.

According to one reading of the Bill-the Mr Hyde version-the eventual outcome of the Bill will be that the NHS opts out of direct health provision and becomes simply a funding body; NHS hospitals, services and clinics become indistinguishable from private ones; everyone competes on business terms for a slice of whatever funds the Government have allocated for health purposes; and what health care a person gets depends on what can be purchased on their behalf in a largely unconstrained, privately run health market. That is a perfectly consistent view of how a health service can be run, but in our country any party that advocates it commits political suicide. Furthermore, of course, it is likely to accentuate health inequalities and overall costs.

The question for us is this: what will prevent such a situation from arising out of a Bill that appoints a competition regulator along the lines of Ofgem to promote competition, that blurs many of the lines between private and public provision, and which removes the Government's duty to provide a comprehensive health service? Hence the importance of today's debate, which, knockabout apart, is crucial to the wider debate on the Bill. To be alarmed by the prospect I have set out is not to oppose competition in principle. The previous Government set up competition and collaboration panels to encourage a degree of challenge in the system. In fact, if hon. Members look at their record, they will see that they were knee-deep in competition initiatives. Neither is holding these concerns to be alarmed by the presence of private business in delivering NHS services. There is not a person here who has not used a private optician or a private pharmacist when they need it. There is a long tradition of involvement by the private sector in the NHS.

Rather, to be concerned about the proposals is to be alarmed by the fear of an unconstrained, uncontrolled market in health-this is a point that has been made

previously-partly because it can lead to fragmentation, potential conflicts of interest, profiteering and so on, but mainly because identifying competition as the main engine of improvement in health care ignores the simply enormous gains in service quality, cost reduction, efficiency and patient experience that can be gained through co-operation, collaboration and integration of services.

The NHS is built on the principle of co-operation, in which we, the hale and hearty, make a moral compact to support the lame and the sick. To make commercial competition the main driver of improvement in the NHS, even if it is not competition on price, would be a serious mistake. It would be to subscribe to a perverse and misguided form of social Darwinism. Competition is a mechanism; it is not an end in itself. The role of competition in the NHS, as seen by the Government, is the real issue. The problem is made a lot worse by the hopeless lack of clarity over how European competition law will apply. We struggled with that issue in Committee. We did not resolve it, and I do not think that we will do so.

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Owen Smith (Pontypridd, Labour: Does the hon. Gentleman share my concern that in today's debate, as in the long period we spent together in the Bill Committee, the Government have failed to clarify how competition law will apply? Indeed, they have sought repeatedly to imply that it will not bite any harder on the NHS. Does not that verge on disingenuousness from the Government, if not downright dissembling?

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John Pugh : I think that that is a bit unkind to the Government. I have been to the Library and borrowed some very big books on EU competition law, and the main conclusion that I have drawn is that the law is not at all clear when it comes to the provision of public services. But that adds to the risks created by the legislation, and gives rise to the awful thought that the fate of our local services, about which we all care, could be decided not by the NHS, not by the Government and not by the public but by case law-European case law, at that-and in the courts.

If we subject clinical services to the same regime to which we have subjected non-clinical services, we will not get the innovative social enterprises strengthening existing provision that people would like to see; we will get large companies financed by private equity muscling in and challenging tendering processes, backed up by legal teams and looking for every weak link or failure to comply with EU regulations. Indeed, that is already happening with non-clinical services.

That is why there is a problem, and it is why private equity is licking its lips. We cannot additionally expect the private sector to come into this game to bid for the unprofitable, high-risk, complex work and not cherry-pick. That is not what businesses do. Good businesses pick cherries, because they need to make a profit. To suggest, as Clare Gerada of the Royal College of General Practitioners has done today, that there is not a problem of untrammelled competition in the legislation is entirely to miss the point. We are not anti-private sector, and we are not anti-competition; we want to see a level of robust pragmatism supported by those with a lifetime's experience of running health services, and a recognition that good health care is essentially a collaborative exercise. If we cannot get that recognition and the acceptance of

the professional bodies for what is embodied in the Bill, everything we say here and every amendment that we make will be utterly pointless.

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Several hon. Members: rose -

Dawn Primarolo (Deputy Speaker; Bristol South, Labour: Order. A large number of people still wish to speak, and we simply will not get everyone in unless I reduce the time limit further, so that is precisely what I am going to do. The time limit for contributions to the debate from Back-Bench Members is now five minutes.

Debbie Abrahams (Oldham East and Saddleworth, Labour: It is a pleasure to follow John Pugh. A lot of water has passed under the bridge since the middle of March, when we last debated the NHS. The Committee tasked with scrutinising the Health and Social Care Bill, on which I served-a baptism of fire-finished its deliberations at the end of March. I believe that it was the longest running Bill Committee since 2002, so it was a marathon stint in which we debated 280 clauses and 600 amendments. During those eight weeks, the Government did not accept a single amendment. Some hon. Members made exceptional speeches, dissecting the Bill in detail and arguing against it. I remember in particular a debate about regional specialist services and how they would be commissioned in future. I am afraid, however, that that was as far as it went when it came to changing the Bill. I was therefore nonplussed when, the day after the Committee finished its proceedings, the Prime Minister and the Deputy Prime Minister expressed their concerns about the Bill and announced a pause in its enactment.

At the same time as the Public Bill Committee was sitting, we saw growing public anxiety about what the Bill would mean to patients and their families. I was contacted by hundreds of my constituents and received a petition signed by nearly 300,000 people from across England. Perhaps that was the motivation for the Government's change of heart or was it just political rhetoric, with the elections looming? There has certainly been no pause in NHS reorganisation in many areas, including my own, where, as I mentioned the other week, it has actually been brought forward.

The public are beginning to see an erosion of the considerable improvements made in the NHS under Labour, and this is what is fuelling public concern. In Greater Manchester, as Peter Thornborrow, one of my constituents found out to his cost, there are much stricter criteria for cataract surgery, as is also the case for hip and knee replacements . .

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