rose to call attention to the quality of care given to NHS patients in both hospitals and community settings; and to move for Papers.
The noble Baroness said: My Lords, I am very pleased to be opening this debate on the quality of care provided by the NHS. We have a broadly worded Motion before us and no doubt the speeches will cover many topics. Before I start, I congratulate the noble Baroness, Lady Thornton, on her new position on the Government Front Bench.
Our National Health Service is one of the largest and most sophisticated organisations in the world and we are right to be proud of it. It is also complex and hard to manage. The debate on how best to fund, control and organise the service is never-ending. This is reflected in constant structural change, which can be wasteful, time-consuming and particularly disruptive for senior staff. The situation has been made even more complex in recent years by the rapid and resource-demanding advance of medical technology.
To go back 20 years, there was a movement in the late 1980s and early 1990s, led by my right honourable friend Kenneth Clarke, the then Secretary of State for Health, to semi-detach the management of the NHS from government. Quarry House is a most imposing building, purpose built on a hill in the middle of Leeds. There the NHS Executive directed operations with a board of distinguished executive and non-executive members, the full time board members spending a considerable part of their working life on the train between Leeds and King’s Cross. Those were the heady days when acute, mental health and community services were converted from the directly managed units of the district health authorities into trusts with their own boards of directors.
Now, many years later, the principles of independent management and degrees of autonomy are still recognised. However, there are difficulties in putting those principles into practice. For instance, in his letter introducing the operating framework and PCT resource allocations for 2008-9, David Nicholson, the NHS chief executive, says:
“The conditions are now absolutely right for developing a framework within which PCTs, in conjunction with their local communities, can set more of their own ambitions rather than having them mainly set by the centre: this Operation Framework is the beginning of that journey”.
This must be a very small beginning to a very long journey. The opportunity for PCTs to set their own local targets will be identified in a category called vital signs, which is to be a set of indicators that has not yet been identified. However, even before knowing what these indicators are to be, the PCTs are weighed down with centrally imposed targets. The five priorities in the “must do” category do not look too bad at first sight, but there is a wealth of detail within each priority. These priorities are by no means all, a count of targets in other categories results in an alarmingly high figure. It is hard to imagine where PCTs will find the time or energy to apply to the as yet unknown vital signs. The word “micromanagement” still rings in the ears. If the Government wish to increase local autonomy, they will need to take a more realistic view of the demands of existing targets. Will the Minister please comment?
Aspects of the programme for an NHS IT system, Connecting for Health, need urgent attention. The programme was launched by Ministers in June 2002 at an estimated cost of £12.4 billion. This would carry all patients' records and be available to all professionals working in the service. Contracts were commissioned across the country in 2003. In London and maybe elsewhere in the country, the community services have so far not received equipment which would enable them to access patient records when on home visits. Contributing to Connecting for Health is a new computer system currently being introduced for community staff in London. This system, known as RiO, is running late and will not be fully in place until the end of 2009. At present, it is not expected that RiO will provide portable equipment such as a BlackBerry for staff working in the field to use to access their own community-held records, or the hospital and GP systems. Despite this big investment, paper records are still being widely used, as there is nothing available which will allow field staff to access and record information while out and about.
More seriously, they are not able to react with speed when they visit a patient who needs prompt attention because the necessary information provided by case notes cannot be accessed. Having community staff who are properly equipped is all the more important with the increasing emphasis on early discharge from hospital, and the wish to keep the chronic elderly safely in their own homes. For staff working in the field, it is essential that they should have up-to-date equipment, and that right from the start this should have been high on the priority list. Will the Minister please tell me why this part of the programme is running so late?
To turn to general practice, here are a few thoughts on GPs' ability to deliver good care. First, there is a perceived gap between medical input and social care. The patient is unwell, a clear diagnosis is made, a treatment pathway is established and clinical standards of care are brought into play. The patient is safely in hospital. This is often not the case. The patient is set up at home and, so long as there are no problems, all is well. If however, on a Saturday, the patient becomes confused and it is difficult to find a district nurse or a community psychiatric nurse for short-term crisis intervention, there is no alternative but to admit to the local district general hospital, with all the formalities and costs that entails. There are ways in which the gap could be filled; for example, with cover by trained staff at the weekend to deal with patients at home, or by admission to the community hospital where, as the condition is not acute, the patient can be stabilised and any tests can wait until Monday. Admission to a nursing home is not an alternative when there are no short-term emergency places.
Community hospitals are a valuable resource and they fill an important gap, especially as the demographic time bomb means that there will be an increasing number of frail elderly living in their own homes. Although there are opportunities for GPs to develop practice-based commissioning, these vary across the country. PCT support and input is important. Some of the services set up by GP practices take the pressure off the local DGH, but in some cases they are seen as a threat to its workload and there are fears that it will become a hospital providing emergency services only.
In his report A Framework for Action, the Minister the noble Lord, Lord Darzi, set out the proposed functions of polyclinics in London. In big cities, where there tend to be many poorly equipped, single-handed practices, polyclinics could well provide an improved service. However, there is a danger in undervaluing the importance of the patient-doctor relationship. Much of the GP’s work tends to be with patients who are frail and inarticulate, causing them to be nervous and uncertain. There is a psychological element to virtually every consultation, and if the GP knows the patient a lot of time and expense can be saved in getting to the core of the presenting problem.
I will now say a little about nurse training and staffing levels in hospitals, which are matters of considerable importance. There are not enough training places in the colleges. We need not only an increase in training places but a positive recruiting campaign. Nor are there enough retraining places for nurses who have been out of service for more than five years. In some instances, nurses are required to pay to retrain. Nursing in the acute sector has become much more intensive, and there is a shortage of qualified nurses who can be directed into specialist care, for instance critical care. Nurses are now able to do more specialised work on the wards and work very closely with junior doctors. Excessively long hours are no longer worked by junior doctors, and they have protected teaching time. Highly qualified nurses provide additional skills and support for their junior colleagues at the point of registration.
There is a shortage of midwives, and with a high proportion already in their early 50s it should be made more attractive to temporarily retired younger midwives to retrain. The Government’s announcement last Monday is welcome. The magnitude of the problem is reflected in the numbers; 4,000 extra midwives are to be recruited over the next three years. It is tempting to ask why the shortage was allowed to become so great before the Government took action. Every effort should be made to ensure that the problem is solved within the proposed three years.
Patient-support staff are an essential part of the ward team, as there is so much that they can do for the patient. Nutrition plays such an important part in recovery, and if wards are well supplied with trained support staff, they can do so much towards helping and encouraging patients to eat. Of course, nutritious and appetising food does help.
Before leaving the hospital scene, I will say a word about MRSA. Hospital-acquired infections and the way in which each successive strain of Staphylococcus acquires resistance to current antibiotics make a fascinating study from the advent of penicillin in the 1940s onwards. However, we are where we are, and every effort has to be made to combat this nasty onslaught on our hospitals. It is widely accepted that the main transmission of Staph. is on the hands. Deep cleaning is fine, and it is good to have clean hospitals, but we all know that it is not the only answer. For instance, in countries where they have lower bed occupancy, they are more successful in controlling the spread of infection. Pre-admission screening, allowing enough time between admissions for thorough cleaning, and rigorous hand washing cannot be stressed too emphatically.
I have commented on several specific areas of healthcare, which are a very few among a great many. I will end with a general point of great importance. The Government must always bear in mind David Nicholson’s aim that decisions will increasingly be made at the local level rather than at the centre. For a publicly funded National Health Service, there will always be some targets, and centrally imposed targets have a genuine place in the area of public health. Beyond that, however, national targets should relate solely to outcomes. Of course, any trust or PCT should be free to set its own internal targets if it wishes. The temptation by the centre to micromanage must be resisted. There will be tension between allowing local initiative and enterprise to develop and achieving and delivering the same standard throughout the country. Maybe we should be more relaxed about equality of provision and postcode funding and give more rein to local initiative and enterprise, which would be a great morale raiser. I beg to move for Papers.
My Lords, I thank the noble Baroness for introducing the debate. I find that I agree with almost everything that she said in her very constructive and wide-ranging speech. I am in a difficulty, because I came in thinking that I had 10 minutes in which to speak. In the past half an hour, I have done a rapid hatchet job, so I apologise if my speech is a little disconnected. The noble Baroness has chosen a subject that could occupy a seminar for several days and there would still be much more to say. To measure quality of care is not simple, but the task can be divided into subjective and objective measures.
First, on subjective assessment, population opinion polls fairly consistently show that the majority of people in the UK are pleased with the care that they receive from the NHS. In a speech last year, the Secretary of State mentioned a survey in which 92 per cent of patients described the treatment that they received as “good”, “very good” or “excellent”. Perhaps surprisingly, 83 per cent of people appeared to be satisfied with existing hours of GP availability.
It could be said that most people in the UK do not know any other health system with which to compare the NHS. They do not know that doctors in France give longer consultations, or that hospitals in Germany are better equipped. On the other hand, Americans can hardly believe that we have such a humane and excellent health service, free at the point of use, compared with the heavy financial burden and anxiety involved in obtaining medical care in the USA. Most of my friends and relatives who have experienced NHS care for a serious illness are full of praise for the standard of clinical and nursing care that they have received. That is more than can be said for some private care. Three of my close relatives have received substandard care in prestigious, expensive private hospitals in London.
Of course, the National Health Service has problems, as the noble Baroness mentioned, the higher level of hospital-acquired infections being one. We all know that poor care is sometimes given and that mistakes are made, some of which receive media attention, where too often the problem is presented overdramatically as a “shock horror” story to increase the circulation of the paper, or perhaps as part of an unwritten agenda to undermine the National Health Service.
Turning to more objective measures of health and healthcare—which are not the same thing—I will share with noble Lords some of the information in this fascinating statistical document on the health of OECD nations. I am afraid that we do not do very well. We are eighteenth out of 27 countries in our infant mortality rate and our rate of low birth weight. That is disturbing because the consequence of low birth weight is a higher incidence of cardiovascular disease in later life. We are approximately half way down the list for heart disease and cancer. But we are showing signs of improvement, partly due to the national cancer plan and the NHS frameworks. The trend is towards an improvement in heart disease, but it is too early to judge the effect of the national service frameworks.
It is recognised that many of these disabling conditions are a result of multiple social, economic and nutritional factors well beyond the reach of the National Health Service. Reports by Derek Wanless and more recently by the Foresight initiative on obesity have pointed out that our major health problems have complex causes that cut across the responsibilities of several government departments—not only in health, but in education, transport, housing, employment, trade and industry, and ultimately the Treasury. All legislation by these departments should be subject to a health impact assessment.
In my final minute, it is appropriate to discuss briefly what is in today’s newspapers on the National Audit Office report on the progress of the contract in primary care. In the quality and outcomes framework that forms the basis of this, doctors are given the option of adding to their income by fulfilling certain activities which constitute high-quality care. Many of these concern the identification of patients at risk of developing the kind of chronic diseases that I have described, which constitute our major health burden, and arranging appropriate care for these patients. Examples are diabetes, hypertension, obesity, cancer secondary prevention, heart disease and asthma. Many of these procedures would be carried out in any case by a good medical practitioner, but the less enterprising who would not have carried out this activity have been encouraged to do so. They have been given a cash carrot and most GPs with this incentive have performed beyond expectation—hence earning higher incomes than expected. It has been estimated that the quality and outcomes framework activity will lead to the saving of 9,500 heart-related problems.
However, I am not a wholehearted supporter of the GP contract. The BMA outsmarted the Department of Health in the pricing negotiations. I look forward to reading the full National Audit Office report.
My Lords, I congratulate my noble friend on securing this debate and for the exemplary way in which she has introduced an enormously broad subject. I pay tribute to the expert remarks of the noble Lord, Lord Rea.
The Minister, whom I welcome to her place today, will certainly in her closing remarks—otherwise I shall be very surprised—remind us of the increases in spending on the NHS in the past few years. I expect her to tell us, for it is the case, that annual spending now amounts to more than £92 billion and that the proportion of GDP devoted to health spending has risen to some 9 or 10 per cent of the total. She may also describe some of the welcome policy initiatives introduced by the Government, not least the reduction in waiting times, and she would be right to do so.
However, she will know, as do the rest of us, that while the amount of money spent is all important, the way in which it is spent is also important. Given that it is our money, perhaps it is even more important. Last September’s King’s Fund report pointed out,
“what is clear is that thus far the additional funding has not produced the improvements in productivity assumed in the 2002 review—costs of providing health services have increased and there is patchy and conflicting evidence on the impact on productivity overall, including little information about community-based care”.
This is important for Ministers because while the public hear what they say about extra cash for the NHS, it is the public’s experience of services on the ground which will form their judgment of the Government’s performance. The noble Lord, Lord Rea, mentioned that only today the National Audit Office has confirmed what some of us suspected about the GPs’ contract—that it has given GPs a great deal more money for doing less, or, rather, for doing things in a different way; and into the bargain it overspent by some £1.75 billion. I suppose that Ministers accept that, because they are to renegotiate the contract.
In Norfolk, one of the early effects of the contract was to cut GPs’ out-of-hours services, thus driving a coach and horses through the concept of community care and putting more pressure on A&E services. Norfolk people are also aware of the cuts in beds and staff and some 400 cancelled operations in the past two months at the Queen Elizabeth Hospital, King’s Lynn, giving what one consultant at the hospital called,
“cheap and nasty patient services”,
as the hospital struggles to meet its debts. I hope that the Minister does not feel that these remarks are deliberately churlish. I have paid tribute to the extra funding of the NHS, but I would remind her—and one was constantly reminded of this when one was in government—that, if people pay higher taxes, they expect to see more and not fewer services on the ground. That is the point made by the King’s Fund report.
All of us in this House are particularly proud of the fact that the NHS review is being led by the noble Lord, Lord Darzi, for whom there is enormous respect here. Will the noble Baroness be in a position to lift the curtain a little on what might come out of the review? I ask her these questions in particular: how, if the report stresses the importance of community-based care—as I am sure that it will—can the disparity of funding between NHS and social services funding be reconciled, when dealing with the same client groups? What will be the policy for small community hospitals? The present policy seems to be closure, which is deeply unpopular with the public—and indeed with some Ministers who have campaigned against it in their constituencies. I hope that the review will recognise the importance of these units, not least because of their role in easing bed blocking, particularly in rural areas because they are easy for a widely scattered population to access. What account will be paid to the needs of rural areas, where care in the community is costly, partly because staff have to travel to clients, and patients themselves face ever-increasing expense in getting to health facilities? It is almost prohibitive now, given the costs of fuel and hospital car parking, which are a double whammy for rural populations.
I am limited by time constraints. Unlike the noble Lord, Lord Rea, I had some warning, but perhaps I may sum up: terrific on resources; jury out a little bit on their effective use.
My Lords, I add my thanks to the noble Baroness, Lady Eccles, for introducing this debate and I agree with her themes of devolution and quality. I have experienced recently the best and the worst quality of care for very aged relatives, and I know how distressing it is when it does not work well. I have also given the best and the worst care in my clinical years and know how complex it is to get it right.
Getting quality right is not just a UK problem. Let us face it, there are quality problems—particularly on quality of outcome—and care failures around the globe, including in the much-vaunted US system. But there is no doubt that our directly managed structures in the NHS positively divert clinicians and managers from sick patients’ priorities to feed the beast of governmental process targets which are largely meaningless to clinicians if taken to extremes. We would have to be stupid to think that the recent disaster in the Maidstone and Tunbridge Wells NHS Trust was a one-off; there was nothing unusually poor or wicked about either the clinicians or senior management there, they were just worrying about something else. Things are very bad in other places, but they are not as conveniently measured as C. difficile cases.
I am a board member of Monitor, the NHS foundation trust regulator, and make no apology for talking today about our view on what it will take to improve quality across the NHS. I define quality as safety, clinical outcomes and patient experience. The answer lies not just in providing those incentives for providers, but in changing commissioning. We know that if we get joint commissioner-provider incentives and sustained priorities, we can make significant progress; waiting times are a clear example. Too often, we have had too many inconsistencies, too many themes, and not enough time to change. If we want quality to improve, we have to make it the absolute priority and stick with that. That will require major political support for the sort of reconfigurations that I hope the Darzi review will recommend in order to reduce the variability. We need public support for that, which will be by ensuring that they have the information. Performance league tables in education make it clear to parents how they should choose schools, and students should choose universities, by using multiple metrics. We should replicate these models in health so that the public can exert real pressure on services.
I want to talk about primary care trust commissioners, because they are in a mess. What were the local Maidstone PCT commissioners doing, frankly, when buying such lousy care from the trust? The answer is that they were navel-gazing while being reorganised. PCTs must be held accountable by SHAs for the quality of the care they purchase. It requires performance regime change; instead of focussing on in-year finance and access, they must focus on quality of outcome. That means investing in skills; at the moment we spend half a percent on investing in commissioning skills. Any health insurer in the rest of the world spends about 5 per cent, minimum. A medium-sized health insurer would have, perhaps, 15 to 20 trained actuaries for risk and pricing analysis, but PCTs have none. It is about buying clinical services and yet clinicians are not involved. There is almost no clinical leadership in PCTs; that needs massive development and expansion. About 90 per cent of the 350,000 PCT employees are employed in provider services, even though that accounts for only about 10 per cent of their budgets, while only 2.5 per cent work on commissioning, which accounts for 90 per cent of their budgets. Will the Government now crack on with the separation of provider and purchasers in PCTs, and concentrate on the job that they are supposed to do?
We need outcome and quality standards: probably a mixture of process and outcome metrics, which we already have on mortality rates, readmission rates, patient satisfaction, infection rates and so on. We must have information down to individual clinician level. In fact, much of that is already available. There is also a great deal more that we could get out of patient surveys, although at the moment we do not survey the very patients who are most at risk of poor quality, such as the confused older person entering hospital, nor their carers, who could give us a pretty clear picture of how they felt about their times there.
On incentives, briefly: we know that we have public-funded services such as the HEFCE way of funding, through the research assessment in universities, which is excellent in that respect and which we could easily replicate. I am running out of time, so I will just say that we can address these matters easily if we give priority to quality in the way that it deserves.
My Lords, I begin by congratulating the noble Baroness, Lady Eccles of Moulton, on securing this debate and introducing it so very well. There is no doubt at all that the NHS has improved considerably during the past few years. The infrastructure has improved, staffing is better than before and the basic NHS culture is undergoing some extremely important and desirable changes. I welcome all that and the fact that our expenditure on the NHS is increasingly coming up to the European level—something like £43 billion during the past five years alone.
I have only about five minutes when I had expected to have more, so, having congratulated the Government, I want to concentrate on where the NHS needs to go and how it can be improved even further. I will end with four or five major suggestions, based partly on my experience here and partly on my experience of having lived in other countries where I served as a visiting professor.
First, it is striking that there is a great deal of inequality between different regions and different socio-economic groups in life expectancy, infant mortality and general quality of life. If we are not careful, that will increasingly become a bone of serious contention, even protest.
Secondly, as my noble friend Lord Rea pointed out, the National Audit Office has confirmed that the additional funding that has gone into the NHS has not produced the commensurate and expected level of improvement. Partly that is because too many administrators, as opposed to doctors, have been involved and there has been too much paperwork. There have also not been, I am sorry to say, properly negotiated contracts with GPs. Quite a lot of money has gone into GPs’ pockets; I do not begrudge them that, but at the same time it has not resulted in the kind of improvements that one had hoped for.
My third point is slightly different. The NHS will always be short of resources, but how do we tackle that? One way is to control not just the growing administrative hierarchy but one or two other areas. Millions of pounds-worth of medicine are wasted and we need to find ways of reducing that wastage by greater prescriptive self-restraint on the part of GPs and greater public awareness. We could also, perhaps, ask drug companies to produce drugs so that if I were to use a part, the rest would not be wasted but could be reused. I know that that is being done in some countries.
Equally important, I have always been struck by this: why have we not, during the past 50-odd years, developed the culture of philanthropy that characterised the Victorian age and is to be found in other societies? In many countries, when people die, they are prepared to leave a part of their money to colleges, universities or schools. Why is that practice not extended to hospitals? Why would people not say, “I want to donate for equipment or for a bed, or to build a room, or to endow the post of a consultant or registrar”—when some are in a position to do that? That culture of philanthropy exists in other countries. That is what characterised our own country during the Victorian period and I can say, from some experience, that it is also to be found in parts of India. With suitable tax breaks, it should be possible to encourage a culture of medical philanthropy in our country. I would develop this further if I had time, but I shall rest the general point there.
We should also improve the efficiency of communication between hospitals and doctors. Let us take something simple. A GP refers you to a hospital doctor for an X-ray, a throat swab or a blood test. The hospital report takes days and days to arrive and in the mean time the poor GP is paralysed and the patient continues to suffer. I am sure that it should be possible to organise things in such a way that, within 24 hours of a test being done, the hospital can phone the GP and say, “These are our findings; please treat the patient accordingly”. We also have the increasingly common situation of hospital appointments being cancelled at the last minute, as if doctors’ convenience alone matters and many of us have nothing better to do than to hang on for the appointment to come through.
I have one other point, which is structural. In this country, there is a tendency to think in terms of bipartite structures. We had universities and polytechnics; we have solicitors and barristers. We seem to have transferred that philosophy to hospitals, so that we have GPs on the one hand and consultants and hospital doctors on the other. I do not know of many countries where that kind of division takes place. Why it has come about here is a long story, but I suggest that it should be possible for GPs to become semi-experts in particular areas, if not as expert as consultants. It should then be possible to have, rather than a single GP, a group of GPs working together, with each specialising in such things as ophthalmology, ENT or cardiology, so that in-house GPs are able to provide many of those services before they refer patients to consultants. If they need certain guidance, it should be possible for them to ring up the hospital consultant and ask, “In this case, given my expertise and what I have found, what do you think I should be doing?” rather than waiting for weeks until the patient is referred to the hospital consultant.
As my time is up, and I dare not alienate my Whip, I should stop. I believe that there needs to be some radical rethinking if we are to get maximum advantage out of the money that we are spending to make our system more efficient than it currently is.
My Lords, I am most grateful to my noble friend Lady Eccles for giving me a chance to raise again something very close to my heart. For over five years, ever since the Government blocked my Patients’ Protection Bill, which would have stopped the appalling practice of deliberately withholding food and liquid from sick people in hospital, I have been trying to bring an end to such inhumanity. I am shocked that it seems so difficult, if not impossible, to do so. There is no time now to catalogue the ways in which my frequent requests in Parliamentary Questions, speeches and letters to Ministers have all been stolidly blocked, although initially they have been received courteously by those Ministers.
Last year, I submitted 25 cases, all of which I had checked personally, to the noble Lord, Lord Hunt of Kings Heath, then the Minister responsible. I will detail what happened to just one. An 80 year-old man was admitted to hospital after a heart attack. He was in an advanced stage of motor neurone disease. The staff were told that but never helped him to move at all. When he needed the lavatory, he called repeatedly for help, but was totally ignored. After about two hours he wet the bed and felt ashamed and upset, which saddened me. That was not the only complaint. Food brought to him was always placed out of reach. He begged for the plate to be placed nearer but he was ignored. The food was removed untouched and after quite a short while he became very weak and suffered bed sores, which his wife dressed because no one else did. The family demanded his discharge from hospital and he was sent home in freezing weather, with only a very thin cover, arriving extremely cold. He died a week later.
I will read the trust’s report on that complaint. It says:
“Malnutrition Universal Screening Tool (MUST) being introduced … Red Tray system”—
whatever that may mean—is now in place and there is,
“further work to develop a flow diagram”.
The report goes on:
“Adapted cutlery. Very clear statement about health care professionals responsibilities for ensuring the nutritional needs of patients are met”.
“Very clear cycle of audit programmes. Illustrated Menu cards and menu cards in different languages”.
That was all that was said in answer to my specific complaint. There was no word about help with the bed sores; not a syllable about lack of attention when the patient needed the lavatory; no comment on food being put too far away; and no word about a lack of a warm cover in the ambulance. There was no apology and no acknowledgement of any poor care at all. The final word by the chief executive on all my 25 cases, some of which apparently received no investigation at all, is in the final sentence of a three-page letter, bringing all my complaints to a close. The chief executive said:
“I am assured that appropriate policies on nutrition and hydration are in operation and that negligence has not occurred. In light of the depth of the investigation”—
that is rich—
“and findings I do not consider that a further independent investigation will be necessary”.
If anyone can link any part of the complaint that I made about Mr Smith in that Suffolk hospital with the answer that I received, I will give them a small prize, if not a large one.
Of course, all hospitals hate to admit that they are not always perfect and in a thousand ways, of course, they do an excellent job most of the time. I am not trying to be accusatory, but to ignore unpleasant allegations of bad treatment of sick people and to go on and on because it is embarrassing to admit that it is happening really cannot be permitted. I give warning that such complacent blindness will not silence me or other colleagues in all parts of this House who are concerned about this matter—there are battles ahead. With all my heart I wish the noble Baroness a good and, I am sure, successful time in her office. She has my trust and my admiration. I hope that she will listen to what I have said.
My Lords, I thank the noble Baroness, Lady Eccles, for initiating this debate and for her very important contribution. Today there is much evidence of excellent care being delivered in the NHS. However, there is also evidence, as we have just heard, of poor-quality care that attracts public and media attention as well as published reports from the Healthcare Commission and the professional regulatory bodies. Inevitably the spotlight highlights poor quality.
I declare a background in nursing. My passion in life is to see an improvement in the quality of patient care both in hospital and in the community. Delivery of care is by the multiprofessional healthcare team, each member having an important role to play: doctors, nurses, midwives and the professions allied to medicine. However, evidence points to the fact that 80 per cent of patient care is delivered by the nursing staff.
The noble Baroness, Lady Shephard, referred to the increase in the allocation of funding. Between 2004 and 2007, the numbers of nurses and midwives on the effective register had increased by a total of 26,400, making a grand total of 686,886 nurses and midwives, but we still see shortages. So where does the root problem lie? The recommended ratio of registered nurses to support workers should be 65 to 35, but the recent NHS Healthcare Commission report on the Maidstone and Tunbridge Wells NHS trust stated that 14 out of the 20 wards were below the recommended ratio. Evidence shows that the quality of care to patients suffers if there are insufficient registered nurses delivering care.
I was recently invited to visit a trust in north-east London that had a huge financial deficit, a very high level of nursing vacancies and poor staff morale. During the visit, I met 24 matrons from the trust; I spent two hours in discussion with them. They admitted that they had been demoralised, but things were improving under new management and gradually they are being remotivated. They expressed the view that the background stemmed from understaffing, lack of clarity of roles and lack of authority. They were unable to introduce simple changes to improve patient care because their accountability was to a middle manager who held the budget. They quoted a history of a high incidence of bed sores and traced one of the contributory causes to the very poor state of the linen. That was not rectified until the new director of nursing arrived. Within a short time, 40,000 new sets of linen were ordered. The concern of understaffing was being addressed and an advertisement brought forth 250 newly qualified graduate nurses. All of them were given a simple numeracy task to calculate drug dosages and a short written answer to plan a patient care pathway. The result was that only two passed with 100 per cent, showing that only two were safe to carry out the administration of drugs.
The third person I spoke to was a modern matron in the south of England. He observed:
“Pre-registration training still leaves the newly qualified registered nurse unprepared for the role; the government is playing high on the role of the matron and their ability to drive the infection control agenda and clinical standards. In reality matrons lack a power base. They are, in many cases, structurally below the managers and even when their grade is higher they are still not party to management issues until cascaded to them. Matrons report to care managers when we feel we should be managed and report to the director of nursing”.
A great deal has still to be achieved. There has to be a culture of care from the bed to the board and the board to the bed. Board members need to know what happens to the patients in terms of the quality of care being delivered and not just concentrate on the finance and targets so that the service can be cost-effective and care-effective.
I now speak with great passion on what patients and the public really want to see: an identified person at board level accountable for the performance management of care. Many patients would say “Bring back the matron”. The Government might respond by saying, “We have brought back matrons”. Yes, but with no clear authority or accountability in many places. The trend, yet again, is for some trusts to appoint a nursing adviser to the board, not an executive director of nursing.
The nursing profession has suffered for the past 20 years as the result of the introduction of general management. There must surely be a need for an executive director to be accountable for the performance of care. This could be the nurse, or a psychologist in a mental health trust. Is it not time to right the wrongs of the past 20 years in the interest of improving quality and safety for patients by adopting the recommendations so clearly set out in the report commissioned by the Burdett Trust for Nursing, Who Cares Wins: Leadership and the Business of Caring?
I welcome the Minister to her seat and wish her every good wish. Can she please agree to see that this proposal is forwarded to the noble Lord, Lord Darzi of Denham, for inclusion in his final report? I am sure patients, the public and the nursing profession would more than welcome this important step in taking the NHS forward towards, in the words of Sir John Tooke, “aspiring to excellence”, and the vision of the noble Lord, Lord Darzi, for a world-famous health service.
My Lords, I, too, welcome this opportunity to call attention to the quality of care given in the NHS. My noble friend Lord Rea spoke of the USA. I have recently returned from an extended visit there, where the debate in the primaries is about who can afford to be ill and who can afford insurance. Those that have insurance are concerned about whether it will cover their possible illness. Quality is absent from the debate. So I welcome a debate where a publicly funded service is common ground. The NHS should not be there for opportunist politics. It is part of the progressive consensus which means that policy should be principled, based on our values and aspirations. I congratulate the noble Baroness, Lady Eccles, on setting this tone when opening the debate.
There seem to have been two important recent announcements about our health service: first, the review announced in June to be conducted by my noble friend Lord Darzi; secondly, the announcement in July by my right honourable friend Alan Johnson that there will be no further centrally directed top-down restructuring in the foreseeable future—the kind of thing which concerned the noble Baroness, Lady Eccles. The Minister confirmed that the purpose was to enable the NHS to keep up with the changing demands and expectations of patients: to adapt to change, to the ageing population and to the unexpected rise in childbirth.
My noble friend Lord Parekh and the noble Baroness, Lady Shephard, gave us details of the unprecedented levels of government investment in the NHS. It is only right that this should happen. After all, we have a population that knows what it wants, and wants to choose. We know that we have a population that wants to choose about end-of-life care. Is the health service being responsive to the changing needs, attitudes and expectations of these users?
Noble Lords will be pleased to know that I am not going to go over all the arguments. We debated them thoroughly when we debated the Bill of the noble Lord, Lord Joffe. My point is that if 80 per cent of the population want this choice—and your Lordships’ Select Committee confirmed that figure—then end-of-life care must be included in a review dedicated to responding to the needs and choices of NHS users.
I hope that the Minister will not say that the review will not consider the option of medically assisted dying for terminally ill patients on the grounds that it is currently against the law and that this is therefore a matter for Parliament and not the Government to decide. I congratulate my noble friend Lord Darzi on being rather more open. His response to the Dignity in Dying campaign was to invite its members to get involved in the review; presumably to develop a more patient-centred approach to end-of-life care. If the NHS develops a more patient-centred approach, then Parliament can be more supportive and more willing to change the law.
I put it to the Minister that it is entirely in keeping with the stated aims of keeping up with the changing demands and expectations of the public that there should be a system for recording a personalised end-of-life care plan; a plan which enables people to express the treatment and care that they want, including assisted dying. Of course there should be a co-ordinated, consistent and continuous use of existing best practice techniques. At the end of life, people often have more than one medical condition; it is rarely a simple battle. This choice—with safeguards—is what the majority of the population want. I put it to the Minister that this is entirely in keeping with the stated aims of her department's reform.
My Lords, I had not intended to take part in this debate, so well introduced by my noble friend Lady Eccles, as my inevitable reference to the current situation in the provision of NHS dental services has been on the Minute under “Other Motions for Debate” for some while, and I hope to have a time allocated for more comprehensive debate on this important subject in the near future.
I changed my mind last Tuesday when I saw the headline in the Daily Express which said:
“11 million can't afford dentist”.
Apparently, 11 million British adults have not seen a dentist in the past two years because even a check-up is too expensive. The article then posed the question that I have asked successive Departments of Health for more than 30 years: why can the public have all their medical treatment free, but have to pay for their dental treatment? It is simply not acceptable that dental care has become a luxury for those who can afford it. Dentistry is not, and never has been, “free at the point of delivery”.
The issue that must be resolved is why the Government and the Department of Health believe that NHS dentistry is getting better while the patients, dentists, dental staff, technicians, the British Dental Association, the Dental Practitioners’ Association and everyone connected with the provision of dentistry believes that it is getting worse? The recent survey on access to NHS dentistry by Citizens Advice prompted a warning from the BDA that primary care trusts and dentists must be properly supported if the Government are serious about improving access for patients. Its survey suggested that 7.4 million people in England and Wales have not been to an NHS dentist since the implementation of the reforms in April 2006, with approximately 2.7 million of those patients going without treatment altogether as a result of problems in accessing care.
Perhaps the issue will be resolved by the Health Select Committee in another place, which is currently inquiring into dental services. I welcome its inquiry, although it is clear to me that the members of the committee were almost as perplexed as patients when it came to understanding the systems of charging for dental treatment and for payment of dental practitioners. I remind your Lordships that the previous minimum charge of £6 has risen more than two and half times to £15.90. The dentist is paid according to the number of units of dental activity he does, which does not reflect the amount of work done or the time taken to do that work. The value is set as a reflection of work carried out in previous years and can carry a different value for individual dentists in the same practice or in different parts of the country. The accumulation of a fixed total of UDAs for each year is set, and if the target values are not reached, PCTs can demand repayment. In 2006-07, 48 per cent of practices did not achieve their UDA targets. That is becoming a serious problem for many practices, and I am aware of dentists who cannot cope with the stress of the claw-back and the potential reduction in future funding. That is why there is a continual drift into the private sector.
The department also underestimated the patient charge revenue resulting in a £159 million shortfall in the dental budget. To commission dental services successfully, PCTs must have the right resources in terms of funding and expertise and engage with local dentists and patients. The varying success with which PCTs have been willing or able to do that has resulted in a new postcode lottery of NHS dental provision. The difficulty faced by some PCTs when commissioning dental services results from their budget being based on previous spending levels, therefore areas which were historically underfunded before the new contract continue to be so. The theory is that areas of deprivation could have higher value UDAs to attract practitioners into those areas. The BDA has called for the Government to allocate full dental budgets for PCTs so that they are no longer reliant on patient charge revenue. PCTs were forced to cover the deficit by a combination of commissioning less dentistry and implementing inflexible performance targets for dentists. Reliance on patient charge revenue ensures that PCTs’ dental commissioning budgets remain unpredictable for future years. This funding predicament faced by PCTs comes in the wider context of the chronic underfunding of NHS dentistry, on which less is spent now than in 2002-03.
Most dentists work in a mixed economy, providing both NHS and private care. The relationship between the two is complex, and many practices effectively use private care to subsidise NHS work. The move towards the private sector is prompted by the opportunity to spend more time with individual patients and focus more on prevention. Most dentists do not experience any significant increases in income.
As I have said in previous debates, there are about 120,000 people working in NHS dentistry: dentists, nurses, receptionists, practice managers, technicians and members of the community service. They all want the NHS to work. At a time when £100 billion is going into the NHS, patients should not have to pay for private treatment, travel miles, go without dental treatment or use superglue to fix teeth or pliers to pull out loose teeth. The Government must listen and act urgently.
My Lords, I thank the noble Baroness, Lady Eccles of Moulton, for giving us the opportunity to debate the most important aspect of the NHS: the quality of care it gives to patients. Recently it has become ticking boxes and establishing what the costs will be, not putting the needs of patients first. The Department of Health has asked the noble Lord, Lord Darzi—Professor Darzi—to carry out the NHS review. The Secretary of State for Health said:
“we want to improve patient care, including providing high-quality, joined-up services for those suffering long-term or life-threatening conditions, so that patients are treated with dignity in safe, clean environments.”.—[Official Report, Commons, 4/7/07; col. 962.]
He also said that patients will have a choice of where they are treated. I agree with all that, and I ask the Minister to explain how it will be achieved.
What patients need more than anything when they are treated in hospitals or community settings is the correct diagnosis. Why do many patients have to wait two weeks for the results of a chest X-ray or a blood test in such places as Maidenhead? When my son became ill in Panama recently, he got the results of a blood test within 24 hours. Surely we can do better.
I now speak as president of the Spinal Injuries Association to say that many of its members are concerned about the difficulties that the National Spinal Injuries Centre at Stoke Mandeville Hospital is having coping with the number of patients needing specialised care. I was a patient in that unit at that time of Sir Ludwig Guttman. He pioneered the specialist treatment for paraplegics and tetraplegics, who do not feel from their lesion down and who have special medical needs and nursing care involving bowels, bladders, skin care and the very specialised problems of autonomic dysreflexia—this is to do with blood pressure. Doctors, nurses and physiotherapists came from all over the world to train at that unit. My very good friend Lady Darcy de Knayth had great trust in that spinal unit, as do many others. I was so sorry that she was unable to go there, which was her wish. What does this say about the Government's choice of five hospitals for patients?
After a meeting yesterday with the health Minister, the noble Lord, Lord Darzi, I see a glimmer of hope, as he has promised to look into the problems at the spinal unit. I hope that he can restore it to its former high standard of care with dedicated leadership, which is so needed. At the moment, it seems to have no slack in the system and, with bed blocking, it cannot take emergencies—a very worrying situation.
So many improvements are needed in NHS care, one being nourishing, appetising hospital food to help patients back to good health, and nurses who will give TLC when helping them to regain strength.
I end by saying how horrified many people were when they heard that Jessica Randall of Kettering had died at 54 days-old after 30 members of staff failed to protect her from abuse and murder by her father. Surely someone should have been taking responsibility. The Government have the responsibility. There was a total lack of leadership. Have we learnt nothing from the huge inquiry into the case of poor little Victoria Climbié? We must become a more caring nation, and so many aspects of health care must be improved.
My Lords, the debate of the noble Baroness, Lady Eccles of Moulton, gives the House an opportunity to look specifically at one of the Government’s manifesto commitments: healthcare at the point of need. Like other noble Lords, I thank her for this opportunity.
With the indulgence of the House, I begin by contrasting two stories, one from a poor country and the other from Great Britain. I was in Grenada during the Recess. A young child of six was badly bitten by a dog. Immediately, there was a great panic, with everyone giving a view of what should be done. I joined in and said, “Call an ambulance”—there were blank stares—“get him to the medical centre”. The mother looked at me and said, “I can’t afford it. If I call the doctor, I will have to pay him and pay for any medication”. Needless to say, I paid.
Returning here, on Sunday after Mass at my local church in Greenwich, I entered into conversation with one of the parishioners, as one does. I said, “How is your husband?”. She said, “Did you know that he had a heart attack while you were away?”. “How is he now?”, I asked. She said, “He’s doing very well. The hospital was marvellous. He was there in 10 minutes and they saw him straight away. They were so good to me and my family. The doctor told me that he was a lucky man to be alive”. I asked, “How much did it cost?”. She said, “Nothing at all, it was all on the NHS”. He will be there for at least another week, and we are all relieved to see the great improvement in him.
What a difference between a small developing country and the United Kingdom. Of course, that got me thinking of this wonderful service, the National Health Service. I know that all noble Lords during this debate have told different stories, but let us pause for a moment and consider what the Government are offering the people of Britain and how lucky we are to benefit from healthcare at the point of need.
On 21 February, the Minister, Ivan Lewis, announced a £20 million cash boost to improve palliative care services for children with life-limiting and life-threatening conditions. The funding boost will enable some of the country's very ill children to be cared for. If they are incurable, they will have the choice of saying whether they wish to die in a hospice or at home. There is currently a grant of £27 million over the next three years for children’s hospices and home care. This announcement extends the Government’s support for a further two years, with funding of £10 million a year until 2011.
On 18 February, the department’s target of reducing by 40 per cent deaths from cardiovascular disease for people under 75 has been met five years early. The coronary heart disease national service framework progress report published on 18 February states that the early delivery of the target has been made possible because waiting times for heart surgery have dropped dramatically since the introduction of the framework in 2000. No patients wait more than three months for heart surgery, compared with more than 5,500 patients in previous years. Prescriptions for cholesterol-reducing statins have more than doubled in the past three years, cutting both mortality from coronary heart disease and the yearly number of heart attacks. Emergency care is delivering thrombolysis more quickly for people suffering a heart attack. In early 2001, 24 per cent of patients received thrombolysis within 60 minutes of a call for help. Now it is almost 70 per cent.
We now know that National Health Service funding rose from £69 billion to £92 billion in the financial year 2007-08. Since 1997, when the present Government took over, staff numbers have grown by more than 224,000 appointments, including 1,300 GPs. Job satisfaction levels are at 73 per cent. We now have some truly remarkable figures to back up the claims that healthcare at the point of need is not a slogan, but a fact. It is true that we still have a long way to go—other noble Lords have given us many examples—and that we still have a critical public, but I ask noble Lords to compare this with countries in which sick people have to pay for their care, however large or small the bill. I am sure they will understand that the people in the hospitals or the caring professions are not robots but people who are working at their best. If government funding is well delivered, they will be able to improve the service. I suggest to the Government that it might be useful for anyone who has had medical care to receive a bill that says, “Paid for by your National Health Service”. The people of this country would be able to appreciate the wonderful gift of healthcare at the point of need.
My Lords, I too am grateful to my noble friend Lady Eccles of Moulton for giving us this opportunity to debate this subject. It is the first time that I have ever spoken in a debate of this sort, because the amount that I know about running hospitals and healthcare could be put into a nutshell, leaving ample room for the nut. I have always been lucky to enjoy very good health until last year. I was taken ill shortly after the Recess started, and in the latter half of last year and at the beginning of this year I became an expert in being cared for in a variety of different hospitals, so I shall now give the House my observations as the person at the other end.
When I was taken ill, I was taken to an accident and emergency department in a hospital not in London but in the West Country. I can tell your Lordships only that it is a miracle that I am still alive. It was exactly as the noble Baroness described the hospital down in Maidstone in Kent. I will not tell your Lordships which hospital I was in, but the wards were filthy. Underneath the bed next to me was a piece of dirty cotton wool, and there it remained for seven days; the ward was never cleaned. It was a gastroenterology ward, with lots of people with very unpleasant infectious diseases. The ward, the tables, the beds and the bathrooms were not cleaned. I was extremely infectious at that time and no precautions were taken with me at all. The staff were furious when my wife wanted my bed cleaned when it clearly needed cleaning. I was just lying there, a pathetic person. It was appalling.
The nurses, who probably are the most important people in this complex area, were what I would describe as an accurate reflection of many young women in Britain today. What do I mean by that? I shall now break your Lordships’ rules and read the next bit, because I thought very hard before I wrote it. The nurses who looked after me—not all of them; we should never generalise and there were one or two wonderful ones—were mostly grubby, with dirty fingernails and hair. They were slipshod, lazy and, worst of all, drunken and promiscuous. How do I know that? If you are a patient, lying in a bed and being nursed from either side, the nurses talk across you as if you are not there. I know exactly what they got up to the night before. I know how much they drank and what they were planning to do the next night, and it was pretty horrifying.
My bed was next door to the nurses’ station, so you could see how the whole place was being run. Actually, you could not: I have seen lots of things being run, but after a week, I could not tell you who was in charge. I had absolutely no idea who was telling who to do what. My view is that nobody was telling anybody.
The man opposite me was dying. I imagine he died two or three days after I left. I do not know what he was dying of because he was not doing a lot of talking. But I do know that he virtually died alone. The nurses thought that he was a nuisance. They changed his bottle, gave him his pills, occasionally fed him and propped him up. But basically this man died alone in a British hospital in the 21st century, and I had to watch him do it, which was pretty unpleasant.
I was saved from that and I have a happy ending to this story. My wife very kindly kidnapped me and put me in an ambulance, on the advice of my London consultant. I was brought up to London to the Chelsea and Westminster Hospital, which is where the story changes. I went to the Thomas Macaulay ward, which was completely incredible. The nurses, of every nationality, size, shape and colour, were wonderful. I was discharged from the country hospital. When I arrived in London I had two operations in 24 hours. I am quite certain—as were all the staff, although they would not say it—that if I had not had them I would have died. The hospital in London was wonderful. The nurses were marvellous. I do not know how, but it worked like clockwork. It was spotlessly clean. It was everything that it should be or could be anywhere.
But some things apply to both places. I have queued in many departments and met many consultants over the past six months. It is perfectly clear that there is far too much paper. Everywhere is swamped with paper. Everyone asks the same questions and fills in forms. Every department is covered in completely pointless paper. Last week, I saw one of my consultants. As I was leaving, he said, “By the way, what do you weigh”? I said, “What on earth do you mean, what do I weigh? Why do you want to know”? He said, “I do not want to know, but I’ve got to tick the box on this form or they will make you come for another appointment and weigh you. I run an outside clinic twice a week and 60 of my patients twice a week are weighed. I don’t care what they weigh. They don’t care what they weigh. But the form says that we have to weigh them”. How ridiculous is that?
Dispensing drugs is really simple. You and I call it retailing. Every week when I get my drugs, I watch them doing it and it takes 40 minutes. Over the road, Waitrose, the supermarket, is doing exactly the same thing really well, so why cannot these people do it? It is a shambles. It takes 40 minutes to get a drug which you can see sitting on the shelf. Why is that? It is because they have never been trained.
My last point is about the clerical staff, who probably are the linchpin that holds together these tiny satellites—the departments and areas of a big service in a large hospital. These people make the appointments and make sure that everyone is in the right place at the right time. They are clearly, too, completely untrained. I talked about it with one of my consultants who said that one of the problems is that the junior clerical staff in the National Health Service are desperately keen to help, very well meaning, completely useless and totally untrained. In the past year, I have observed them in 30 or 40 departments and I have come to the conclusion that that is true. The clerical staff are absolutely useless, but very nice.
Of course, this is a difficult situation. There will always be good and bad. In Britain at the moment there is very little that is good enough and too much that is too bad. This Government came in 10 years ago to sort this situation out. It has not been sorted out. It is internationally embarrassing and humiliating that a country of this size and wealth should produce a service which is so horrible.
My Lords, in spite of the fact that older people are the main adult users of NHS services, Age Concern recently pointed out that the policy of care for older people is still not mainstreamed either in policy or practice, and last year the Joint Committee on Human Rights said that a total change in culture is needed if the human rights and dignity of older people are to be protected. I declare an interest as a vice-president of Age Concern.
An obvious example is dementia care. We know that the numbers affected are very large and growing, and yet dementia is only just beginning to feature in the Government’s strategy. Recently I took part in a small inquiry conducted by the All-Party Parliamentary Group on Dementia, of which I am an officer. Its results will demonstrate clearly that the poor and over-use of neuroleptic drugs to treat those suffering with dementia needs immediate attention.
Some 60 per cent of older people in general hospitals suffer from mental health problems, and there is a terrible lack of training among doctors and nurses not just in dementia, but also in depression and acute confusion, which is often not diagnosed. Moreover, many specialists do not get involved in the care of people with these conditions. Pre-registration training in the physical and mental health needs of older people is essential.
We know that the majority of older people are admitted to hospital as emergency patients. Many are vulnerable and nearing the end of life, and the basic standards of care that they need are not always reached. These include privacy when using the toilet, still being admitted to mixed-sex wards and the involvement of their carers not being allowed. We also know that safe and well planned discharge is still only a dream for many. Discharge should be planned either before or on arrival in hospital, and should not be directly to a care home. An example of this was the discharge of a 94 year-old I know well from one of our main teaching hospitals in London. He came in as an emergency in bare feet with pyjamas and a dressing gown and was discharged in bare feet with pyjamas and a dressing gown on the wrong side of the road from his flat. He had to cross that road and get up the stairs. This happened not long ago. Another gentleman nearing 80 was admitted as an emergency to another of our London teaching hospitals and asked for an extra pillow to relieve the pain in his back. It was impossible to find him one all night. Sadly, such problems still arise.
The noble Baroness, Lady Knight, is a champion of better nutrition. We know about malnutrition in hospitals, and many older people are malnourished on admittance, although equally many are not. The noble Baroness, Lady Masham, also made the point that in cases of malnourishment, help with eating is essential. There was a time when nurses did this as part of their routine, and we need to go back to that sort of care. It is essential for those who are frail and vulnerable and who have to go into hospital.
Many people who are terminally ill or nearing the end of their life want to die at home, or if necessary in a hospice, because of the privacy offered and the right to die with their loved ones present, and the loving and tender care they want to be sure they will receive at that point in their lives. Dame Cicely Saunders, who brought the idea of hospice care to the world, would be upset if she knew that so many people who want such an end to their lives are not able to receive it, and die in hospital wards. Again, a great friend aged 102 died a couple of weeks ago in an open ward rather than in a hospice. Around 70 per cent of people still die in that way. This is quite unacceptable. Enormous progress has been made in the development of healthcare, and I acknowledge that and rejoice in it, but there is still a long way to go.
The document, Standards for Better Health, is excellent, but many patients and most of the general public do not know that it exists. Patients need information, so the Department of Health should make information about the standards which patients have a right to expect available for any organisation providing NHS services, whether they are provided in hospital or in the community. We must do that and make sure that people are given the dignified, loving and tender care they need when they are old and frail, and nearing the end of their lives.
My Lords, I, too, congratulate the noble Baroness, Lady Eccles of Moulton, on the eloquent and elegant way in which she introduced the subject, which has turned out to be fascinating. When I was preparing my speech last night I predicted that noble Lords would come at this from a variety of angles, and so it has proved. It is a timely debate, coming as it does at the end of this three-year period of unprecedented financial investment in the NHS and just before the publication of the much heralded review of the noble Lord, Lord Darzi.
The key question running through the debate is how does one determine quality in a service that sets out to meet the needs of 55 million people. Of the speeches today, I would pick out those of the noble Lords, Lord Parekh and Lord Mancroft, and the noble Baronesses, Lady Murphy and Lady Howells of St Davids, as examples of the different ways in which people are tempted to answer that intriguing question.
The problem in the NHS is not lack of quality measures. On the contrary, over the past few years it could be said that the NHS has had an epidemic of quality measures at every level in efforts to demonstrate the justification for finance and the effectiveness of what it does. Core standards, waiting times, four-hour waiting time in A&E, quality and outcomes frameworks for GPs, quality-adjusted life year measures for clinical interventions, NICE evaluations, star ratings and so on. I am beginning to sound like Clement Freud on “Just a Minute”; I could go on and on.
The NHS is a data rich organisation but, as the noble Lord, Lord Mancroft, showed in a graphic way, if your Lordships could do only one thing to help the NHS to be the best organisation in the world that it could be, you would kill the disease of duplication within the NHS. For those who have the miserable job of trying to track information flows throughout the NHS, it must be akin to the children’s game of hunt the slipper; the amount of duplication of information is immense. Who collects the data, where they are held and what happens to them is something of a mystery. Until we can find answers to that it will be impossible ever to truly demonstrate the overall effectiveness of the NHS.
I do not wish to suggest that the development of quality measurements is unimportant—it is not. It is indisputable that in some areas the existence of targets and the development of metrics have led to improvements in care. In cancer treatment, for example, the combination of a national strategy, the involvement of clinicians and charities in the development of research and increased funding has led to new developments such as the introduction of specialist nurses. This has led to better treatment and outcomes for patients. But, at the same time, in one of the flagship services, while there have been improvements with the big four cancers there are still vast areas of cancer treatment where this country lags way behind countries in which there is nowhere near the level of investment that we have.
As a result of listening to clinicians, managers, researchers and patients, my Liberal Democrat colleagues in another place have drawn up our party’s new health policy. We will debate that policy in two weeks’ time. As a democratic party, members still have the ability to decide policy, so I cannot actually say that it is our policy as yet, but I hope that it will be. A key part of that is the understanding that in order to be the best quality health service in the world, patients have to be empowered to improve the quality of care in conjunction with clinicians.
Therefore we have four key proposals within that policy. The first is a pilot of patient advocates dedicated to providing information, guidance and support to patients and carers in navigating the most complex health and social care system in the world. We would replace national targets with a system of universal entitlements, enshrined in the patient contract, which would outline minimum standards of access to primary, secondary and tertiary care services. We would expand the use of individual budgets to specific areas within the NHS, such as core services like treatment for chronic conditions. We would pilot patient-reported outcomes measures that would measure patient experiences while recording the actual benefits, physical and mental, to patients’ health.
There is one key measure by which our proposal will, and should, be judged: the effectiveness with which it enables researchers, policymakers, clinicians and patients to acquire the evidence base that they need for different methods of treatment and care. The real problem we are attempting to solve is the complete disconnect between research proposals, evidence of treatment and cost effectiveness on the one hand and the levels of decision-making within the NHS on the other. That is the key aspect that the system lacks.
The Department of Health has been attempting to make improvements. It has developed the Better Metrics programme, which aims to provide more clinically relevant measures of performance. Will that programme be expanded to other areas of treatment? Through Connecting for Health, which was mentioned by the noble Baroness, Lady Eccles, that programme could be shared with patient groups so that we could continue to develop a policy of putting together patient experience alongside clinical evidence and evaluating the two together.
In the time available to me I wish to mention an area of health services that Members of this House have a duty to address regularly; that is, the provision of services to those people who receive the worst healthcare of all—prisoners. The Sainsbury Centre for Mental Health reported in 2007 that while most English prisons now have in-reach teams and, despite having staffing levels that are less than one-third of the equivalent community mental health teams, they are starting to make a difference to those prisoners who have severe mental health problems. However, the vast majority of patients do not have severe mental health problems; they have lower-level problems such as depression or anxiety. The best that some of them can hope for is to hold out for some Prozac—whether or not it is deemed to be effective.
Last week I spent some time learning about the work of an organisation called RAPt, the Rehabilitation of Addicted Prisoners Trust. It provides a particular form of therapy and support for addicted prisoners, both in prison and in the community. Whereas the majority of services for people with addictions under the Government’s existing addiction strategy, and under the updated strategy as announced by Jacqui Smith yesterday, are dependent on replacement therapies such as methadone therapies for heroin users, the programmes run by RAPt are abstinence programmes. They are intensive and consist of one-to-one help and support for people, based on a policy of abstinence. The organisation’s peer-reviewed results show remarkable achievements; of the people who complete its courses, 30 per cent manage to be completely drug-free. Another 30 per cent are drug-free for a while but may relapse because they return to the difficult situations from which they came.
The programmes are more expensive than replacement treatment such as methadone, but they are highly effective for some people. Will the Department of Health, in seeking to achieve good quality services for some of the most difficult NHS patients, commission a programme of research comparing abstinence programmes with methadone replacement therapies?
We have the most comprehensive health service in the world; we have the potential to have the most comprehensive research base in the world; we have the ability to take different forms of treatment and evaluate their efficacy across different control populations. We also have staff who continue to hold an outstanding public service ethos. They deserve to know whether what they do is effective or, as the noble Lord, Lord Mancroft, graphically showed, could be improved. For their sake and that of all patients, the noble Baroness, Lady Eccles, was right to focus the attention of this House on the key question of what quality is and how we measure it.
My Lords, it is gratifying and perhaps not altogether surprising that my noble friend’s Motion should have given rise to such a wide-ranging set of speeches from all sides of the House, and I congratulate her as much on facilitating that as on her own powerful contribution.
As a number of noble Lords have demonstrated, any analysis of the quality of care given to NHS patients has something of the curate’s egg about it, because we can point to areas where this country leads the world in standards of care and treatment, and other areas where care is poor or even worse. From a political perspective, I have always been ready to give credit to the Government for some of their initiatives during the past 10 years. We now have national bodies whose job it is to oversee and assess the quality of care delivered in our hospitals and care homes. We have a GMC which has undergone reforms whose whole aim is to maintain professional standards and enhance the protection of patients, a process that still continues. We have national clinical directors for many of the key specialties such as cancer, heart disease and mental health. National service frameworks have been developed. Social workers are subject to registration and accreditation. We could add to that list. Nobody can doubt the Government’s commitment to wanting better standards of care for all patients. The large increase in the NHS budget is above all a testament to that.
But intentions are one thing; results are of course another. The whole point of bringing expenditure in the NHS up to the European average was to deliver the kind of healthcare that our European neighbours already enjoy. But we are still a long way from achieving that. Our five-year survival rate in cancer is worse than almost all other EU countries. We are nearly the worst in the OECD for breast cancer mortality. We are well below average in our survival rates for most common cancers, stroke, heart disease and respiratory diseases. When the Government defend their record in health, they tend always to do so in terms of inputs—how much is going into the system. But the test of success is of course outcomes; and we need only look to the words of the noble Lord, Lord Darzi—that passionate advocate of high-quality care—to appreciate how woeful is our record on outcomes and life expectancy in many parts of the country, not least many of the deprived parts of London.
When the Secretary of State took office last summer, he was refreshingly frank about the Government’s record. He admitted that doctors and nurses were fed up with top-down instructions and wanted a sharper focus on outcomes and patients. He spoke about putting clinical decision-making at the heart of service delivery. He talked about making that service responsive to patient choice. These are aspirations to which all of us can surely subscribe.
The sad part is that in so many areas of policy we see Ministers and the Department of Health continue to indulge their controlling tendencies; and the consequences of that are all too often perverse and damaging to patients. Perhaps the starkest example of these controlling tendencies is the target culture, which is still alive and kicking. Targets are blunt instruments: they tend not to distinguish between patients whose need is urgent and those whose need is not. And one creates a distinction between what is targeted and what is not. What is not targeted tends to become a lower priority in the allocation of resources. Patients with chronic conditions, for example, fall outside the scope of national waiting time targets, yet they outnumber elective patients by a wide margin. Clinical priorities tend to get distorted, and the price that we have paid for driving down waiting times has been to compromise standards of care, most obviously in the area of infection control. The Health Protection Agency was quite clear about this in its recent report. The agency identified one factor affecting the management of MRSA as,
“increasing patient movement between wards to meet A&E targets for trolley waits”.
High bed occupancy poses a further risk. The pressures on hospitals to deliver on their targets have undoubtedly led to an increase in bed occupancy rates to levels that are in many cases unsafe. But we should not find it surprising that hospitals are tempted to take these sorts of risk when the operating framework imposed on them by the department contains swingeing financial penalties for breaches of the 18-week target—up to 5 per cent of their elective income, a potentially huge amount of money.
The irony here is that the Government take it as a given that achieving the 18-week target is a cost-effective use of public money. As far as I know, there is no evidence to back up that assumption. The 18-week target is just something that Ministers have seized on as being a good idea. I doubt very much whether the opportunity costs associated with it have ever been evaluated, any more than were the opportunity costs associated with the recent agreement reached on the GP contract.
The Prime Minister has made increased access to GP services his number one priority for primary care. The irony of this should not, however, be lost on us, because it was this Government who, with their eyes wide open, negotiated a contract that has meant doctors have less control than before in delivering Saturday and evening services. The Government are now in the extraordinary position of criticising a situation which they created, yet blaming doctors for it instead of themselves. At the same time, they are flying blind; it was quite extraordinary to hear the Secretary of State say the other day that, despite all the pressure he is putting on GPs to extend opening hours at their surgeries, he has no idea to what extent PCTs are already commissioning GPs to open for longer. How on earth can you gauge the importance of a problem if you do not know its scale?
Many of us wonder whether the policy can in any sense be called evidence-based. The Government's latest GP-patient survey showed that 84 per cent of patients are happy with current opening hours; only four out of every 100 wanted extended opening hours in the evenings and seven out of 100 wanted Saturday surgeries. To force GPs to include opening hours as part of the QOF, instead of clear measures of good patient care, is a seriously misconceived piece of micro-management. The scope for adjusting the QOF in ways that might have improved the care of patients was enormous, not least in the area of brittle bones in the elderly, which costs the NHS a fortune and is an area of care that is not being addressed at all well. But that opportunity has been lost. The QOF has been misused, because access arrangements are not an outcome—and all this because Ministers have lost sight of their own worthy aspirations about devolving commissioning and choice closer to patients.
Exactly the same absence of evidence-based decision-making runs through much of the ideas surrounding service configuration. On maternity units, the Government are looking to centralise care in larger specialist units at the expense of access to smaller units. The claim that is made is that larger units are safer. Absolutely no clinical evidence has been produced to substantiate this; indeed, the Healthcare Commission has given some of its highest ratings to smaller units. What the policy means is that many of these smaller units have closed or are about to. So much for patient choice and easy access. The real reason for these closures is, of course, financial. Very similar issues arise with A&E. Units are being closed, allegedly on clinical grounds, with services being concentrated in fewer centres, but the evidence we have indicates, unsurprisingly, that the further seriously ill people have to travel by ambulance to reach emergency care, the more they are likely to die.
I am fearful that the same kind of top-down approach is going to dominate service reconfiguration more generally. The review of NHS services in London undertaken by the noble Lord, Lord Darzi, contained much good work; but it had a very prescriptive feel to it. He spoke of having a polyclinic in front of every hospital; 150 polyclinics across London; and a GP-led service at each hospital. Polyclinics may well have a place in under-doctored areas. But to make them a universal prescription, at the expense of closing down GP surgeries and perfectly successful hospital departments, really has to be justified in terms of the quality of care delivered to patients. Alternatives—of which there are a number—ought to be evaluated. I do not feel that they have been. What I wish the noble Lord, Lord Darzi, had done was to produce, not a blueprint, or a “template” as he has described it, but a menu of ideas and service models which local commissioners could then take up. Indeed, if I were to think of one message for the noble Lord, Lord Darzi, as he rounds off his nationwide review of the NHS, it would most certainly be that one.
My Lords, first I congratulate the noble Baroness on her choice of topic for today’s debate. She and I are old friends from the Select Committee on Communications; indeed, we have even travelled through the night together. I was not surprised at the quality and thoughtfulness of the noble Baroness’s contribution. We have had ahigh quality debate with a wide spread of different contributions. If I fail to answer fully any noble Lord’s question, I will be happy to write.
There can be few subjects more important than the quality of care given to NHS patients, whether in hospital or in community settings. Indeed, the contributions from my noble friend Lord Rea with his vast experience of the National Health Service and the GP services, the enormous wisdom and experience of the noble Baroness, Lady Murphy, and her work with Monitor, my noble friend Lord Parekh and his remarks about improving communications, and, indeed the noble Baronesses, Lady Emerton, Lady Masham, Lady Greengross, and Lady Knight, and my noble friend Lady Howells present a formidable challenge to a new Minister.
I say from the outset that the quality of healthcare has improved out of all recognition since Labour was elected in 1997. I know it is the job of the Opposition to suggest that this is not the case, but I might say that today the Opposition health spokesman in another place felt the need to honour our enormous progress by making expenditure promises that seemed to, and will be bound to, upset his Shadow Chancellor’s plans, which is a testament to the work and investment of the past 10 years.
I make two points. First, I want to pay tribute, as other noble Lords have already done, to the superb work carried out, day by day and week by week, by the staff in our health and social care services. Every day, 819,000 patients have a consultation at a general practice, 122,500 patients attend an outpatient clinic, and about 60,000 patients are treated as day patients or inpatients in hospital. In the vast majority of these daily encounters with the NHS, as patient survey after patient survey demonstrates, as mentioned by my noble friend Lord Rea, patients receive and appreciate high standards of care delivered by caring professionals who have dedicated their lives to the business of improving health. We should be proud of their achievements, not take delight in knocking them, as some of the most strident of our national media seem to do.
Secondly, I pay tribute to that much maligned breed—NHS managers. Research from around the world shows that high quality organisations do not just happen, they need dedicated and clear-sighted leadership. They, too, have at heart the quality and the safety of the services which their organisations deliver. Furthermore, leadership in the NHS is increasingly being exercised not just by professional managers but also by clinicians, as mentioned by several noble Lords, who have taken on formal or informal leadership roles. As my noble friend Lord Darzi has repeatedly stressed, clinical leadership is potentially the most powerful lever for quality improvement, and we must do all we can to nurture and to celebrate such leadership.
However, I do not want merely to pay tribute to dedicated staff, clinicians and managers; I want to set out a simple proposition: that the best way of achieving even further improvement in the quality of services for NHS patients will lie in the innovation and drive of local clinical leaders, working in partnership with local managers and responding to the needs of their local populations, in an environment which supports and rewards quality. Striving for that quality lies at the heart of the review of my noble friend Lord Darzi, as mentioned by the noble Earl.
I should like to say a few words about the many elements of this supportive environment for quality care that are already in place. Clinical guidance covering most of the significant clinical conditions is now available from the National Institute for Health and Clinical Excellence. We have launched a major initiative to improve capacity and skills in primary care trusts to commission services although I acknowledge that work still needs to be done. PCTs will in future commission services from an increasing range of providers, including providers in the private and third sectors, to meet the health needs of their populations—that was the point of David Nicholson’s letter quoted by the noble Baroness, Lady Murphy—and they will be working closely with councils with social services responsibilities to ensure that people have access to services that are properly joined-up between health and social care.
For instance, a project in Southwark is developing a new approach to help older people who are moving from acute care, providing specialist “step down” facilities to give them time to recover from acute illness while supporting them to make decisions about their future. In this way, more older people are being enabled to return home after a spell in hospital rather than entering care homes prematurely. I think that answers a point made by the noble Baroness, Lady Eccles. That is the sort of programme that needs to be rolled out. Patients already have a choice of provider for acute services, and from the next financial year will have increasing choice when they need treatment for longer term conditions. As noble Lords will be aware, money will follow the patient, providing an incentive to providers to improve the quality of their services to attract additional patients.
The NHS will make increasing use of quality indicators measuring both clinical outcomes and patients’ perception of the quality of the services they have received. Indicators at the level of health communities will enable PCTs, in dialogue with their local populations, to determine the priorities for local quality improvement. The new regulatory regime in the Health and Social Care Bill, which we will shortly debate in this House, will give an underpinning assurance that all healthcare providers are fit for purpose and will place on commissioners a new duty of quality improvement.
However, we fully accept that there is more to do. That is why the Prime Minister invited my noble friend Lord Darzi to undertake a review of the next stages in the development of the NHS. The review team has undertaken a major exercise to listen to the views of patients, healthcare professionals, managers, professional organisations and voluntary organisations on what they see as the new priorities for quality improvement in the NHS and the obstacles to achieving them. The noble Baroness, Lady Emerton, raised important issues concerning quality control at senior level in hospitals. I know that my noble friend Lord Darzi is taking those issues on board in his review. At a more local level, each strategic health authority has set up working parties to develop locally appropriate clinical pathways, as was mentioned. At the end of its work the review team will bring together the experience from each strategic health authority and determine what further work may be needed at national level to support quality improvement. The review expects to publish its findings this summer.
A particular theme of the review will be the role of innovation and the need to ensure the rapid dissemination throughout the NHS of advances in clinical practice. Several noble Lords talked about the need to disseminate information. I will not pre-empt the conclusions that my noble friend will reach on this important topic but I would like to draw to the attention of your Lordships’ House the work of the Innovation Centre which we established in 2005 to ensure that innovative ideas originating in the NHS itself are effectively exploited.
I shall attempt to cover as many points made by noble Lords as I can. The noble Baroness, Lady Eccles, raised several points. Her contention—I will not say “accusation”—was that the operating framework was overly prescriptive and she challenged the increase in targets for PCTs. The 2008-09 document marks the beginning of a new chapter in the journey to transform the NHS and sets out a truly ambitious programme for the NHS over the next three years. This means that local PCTs will control more of the NHS budget than ever before, giving the organisations freedom and flexibility to spend according to the needs of local people. From next year, 82 per cent of the local NHS revenue budget will be in the hands of the front-line NHS. We expect the PCTs to work to the five national priority areas. I would be interested to know which of those areas is not regarded as important, because we regard them all as equally important. We know that is a great challenge for PCTs in determining local priorities and setting local targets to meet the needs of their communities.
The noble Baroness, Lady Eccles, talked about RiO, which is a vital strategic community information system in London. It was selected as a replacement for the existing child health system, but it is being used for considerably wider functionality. Following the start of its rollout, it is now being used in 17 PCTs. Those trusts are already deriving significant benefits, and other trusts will see those benefits. We agree with the noble Baroness that it is essential that members of staff are properly equipped, and we will write to her about the remote access issue that she raised.
The noble Baroness also raised the issue of healthcare-associated infections. She knows that action on healthcare-associated infections is a top priority for the Government. It has been made clear most recently in the NHS operating framework, at a time when we are deliberately trying to reduce the number of central priorities, that we have made this one of the priorities. The measures that have been taken are already having an effect. MRSA infections are on a significant downward trend and have dropped by a further 18 per cent since the previous quarter. For C. difficile, there was a reduction of 16 per cent in the number of cases since the same quarter last year.
Several noble Lords raised the issue of GP access, including the noble Baroness, Lady Shephard, and the noble Earl, Lord Howe. In his interim report Our NHS, Our Future, my noble friend Lord Darzi identified access to primary care as an immediate priority, especially in the more deprived areas, as the noble Earl mentioned. In addition, patient service and public discussions have consistently told us that improving access to GP services should be a priority for the NHS. It is true that a very large proportion of patients are very happy with their GP services, but it showed that 16 per cent of people are unhappy with the opening hours of their GP practice. That is nearly 6.5 million unsatisfied patients. This is being addressed through two major initiatives. First, in October 2007 the Secretary of State for Health announced a £250 million access fund, which will deliver at least 100 new GP practices in the 25 per cent of PCTs with the poorest provision which, as we know, are often in our poorest communities. All health centres will provide core GP services from 8 am to 8 pm seven days a week, offering both booked and walk-in services for registered and non-registered patients.
Secondly, it is our aim that at least 50 per cent of GP practices in each PCT area should offer extended opening hours on weekday evenings and weekends based on patients’ expressed views and preferences. We recently put the proposal to the BMA that would pay for an extra average three hours of work a week and, as noble Lords will know, that is progressing.
The noble Baroness, Lady Shephard, raised the issue of the closure of small hospitals and asked for a peek into the results of the work carried out by my noble friend Lord Darzi. While she will appreciate that we cannot pre-empt the conclusions of the review, we fully recognise the need to provide good access to care to all sectors of the community and we recognise the role of small hospitals. Ultimately, it is for the PCTs to decide for their local populations.
My noble friend Lord Rea raised the issue of low birth weight. It is the case, and he is right, that we in the UK need to address that. We have given a commitment in the next three years to improve the health and well-being of children.
I am aware of the issues outlined by the noble Baroness, Lady Knight, and I have read all the related correspondence. I know that she has been very concerned about this for some time. She has met the Minister, Ivan Lewis, and they have been in communication with each other. My understanding was that each case had been examined and results had been forwarded to the noble Baroness, but if there are further issues that she would like to raise, I would of course be more than happy to discuss them with her. She will be aware of our recent discussions on nutrition, which I will come on to in a moment—in fact, now.
The noble Baronesses, Lady Masham, Lady Eccles, Lady Knight and Lady Greengross, raised the issue of food in hospitals. Noble Lords will know that I spoke about this only a few weeks ago, and we fully accept the importance of ensuring that all NHS patients get the best possible food for their condition. There is no excuse at all for neglect in this area. The Better Hospital Food programme was set up in 2001 to improve hospital food. There are two aspects to this: improving the quality of the food that people eat and, when it has been improved, making sure that they get the opportunity and assistance to eat it. We hope and expect that protected meal times, when non-urgent clinical activity stops on the wards, patients are given space to eat and enjoy their meals, and staff have time to provide help for patients who need it, will make a significant impact on this issue.
More recently the nutrition action plan, Improving Nutritional Care, was published in October last year, following two summits attended by charities, clinicians and nutrition experts. The implementation plan is being taken forward, it is chaired by Gordon Lishman of Age Concern, and I am absolutely confident that if we do not get this right and the situation does not improve, we shall certainly know about it.
My noble friend Lord Parekh talked about communications between hospitals. Most standard tests are back with GPs within 48 hours and further work is ongoing regarding the 18 weeks’ wait. Part of the point is that electronic patients’ records will allow shared records between primary and secondary care.
My noble friends Lord Parekh and Lord Rea, and one or two other noble Lords, expressed views on the National Audit Office report published today. The Government welcome the report and will consider its recommendations carefully. The GPs’ contract, as the report recognises, stems from the haemorrhaging of GPs from the NHS, and it improved quality for the public.
I am informed that I have only one minute left and there are many other things that I wish to say about targets. I am afraid that I shall have to write to noble Lords on all those matters. Perhaps I may say to the noble Lord, Lord Mancroft, that I am sorry that he had a bad time recently. It is important to let the hospital know what happened. I thank noble Lords for their contributions to the debate.