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NHS: Next-stage Review

Volume 703: debated on Monday 30 June 2008

My Lords, with the leave of the House, I will repeat a Statement made by my right honourable friend the Secretary of State for Health in the other place.

“Mr Speaker, as we celebrate the 60th anniversary of the NHS this week, it is befitting that we should acknowledge its successes, secure its strengths and chart a path for its future. Created by fraternity to take the place of fear, the founding principle of the NHS was as clear as it has been enduring: that access to healthcare should be determined by clinical need rather than by the ability to pay.

“The NHS has been a friend to millions, sharing their joy and comforting their sorrow. Today, the service sees or treats a million people every 36 hours, nine out of 10 people see their family doctor every year and a million more operations are performed than just 10 years ago.

“Then, the NHS was suffering from chronic underinvestment. The challenges were too few doctors and nurses, poor equipment and crumbling infrastructure. Patients waited months, if not years, for treatment, waited weeks, not days, to see their GP and measured their time waiting in A&E in days and nights rather than hours. A service whose promise was fair access to all had witnessed patients dying before they could even receive its care.

“This Government resuscitated the NHS and reaffirmed its principles. Today, patients wait no more than four hours in accident and emergency, and by the end of the year they will be able to go from referral by their GP to treatment, with all the diagnostic tests in between, in no more than 18 weeks and normally in nine.

“There have been considerable improvements in the quality of care received by patients and delivered by NHS staff. The improvements for cancer and heart disease alone have saved nearly a quarter of a million lives in the past 11 years. The NHS is now able to deliver the highest quality of care in many medical disciplines and settings.

“The report published today heralds the next stage for the NHS: to deliver the highest quality care for all. It is underpinned by the service’s first constitution, which will empower patients by clearly articulating their many rights, bringing transparency to decision-making and securing its founding principles for generations to come.

“The review has been led by front-line clinicians in every NHS region. Seventy-four local clinical working groups, made up of some 2,000 doctors, nurses and other staff working in health and social care organisations, have developed improved models of care for their communities from maternity and new born to end of life. These are based firmly on the best available clinical evidence and extensive engagement to ensure that they reflect the needs and preferences of local people.

“In common with all health systems around the globe, the NHS faces some significant challenges: ever higher expectations; greater demand driven by demographics; the transformational power of better information; the changing nature of disease and of treatment; and rising expectations of the health workplace. The report puts the NHS on the front foot, seizing the opportunities that these challenges present, rather than simply reacting to their consequences.

“Meeting these challenges demands that the NHS does more to help people to stay healthy and gives them more information, choice and control over their own health and healthcare. Every primary care trust will now commission comprehensive well-being and prevention services to meet the specific needs of their local populations.

“Preventing vascular conditions such as diabetes, stroke and coronary heart disease has the potential to save thousands of lives. Today, about 4.5 million people are afflicted by vascular conditions, accounting for over 170,000 deaths every year. We will launch a new ‘Reduce Your Risk’ campaign to raise awareness and understanding as a precursor to the national vascular screening programme that will begin next year.

“Improving the health of individuals and families will become an increasing focus for GPs. We will work with world-leading professionals and patient groups to improve the quality and outcomes framework to develop better incentives for maintaining good health as well as providing good care.

“As much as the NHS will do more to help people to stay healthy, it will also become a service that responds more rapidly and effectively to the people who use it. Patients will be given more rights and control over their health and care. They will have greater choice of GP practice, with better information to make the best choices for themselves and their families. This will be delivered by a fairer funding system that gives better rewards to GPs who provide responsive, accessible and high-quality services. Choice will not simply be a policy of government but a right secured for all through the first NHS constitution.

“The constitution will guarantee patients access to NICE-approved drugs and treatments. We will give greater support to NICE to increase the speed of its appraisals process so that new guidance is consistently issued more quickly. Primary care trusts will have a new duty to give transparency to their decisions and clear explanations to the public. These measures proclaim an end to the postcode lottery in NICE-approved drugs and treatments.

“These rights will be accompanied by more personal control for patients, harnessing their ingenuity to improve their health and care. Every patient with a long-term condition will be offered a personalised care plan, jointly agreed by the patient and a named professional, so that services are organised around the needs of individuals. For the first time, we will pilot personal health budgets that give individuals and families the fullest control over their care.

“All of the measures announced here today are designed to improve the quality of care that patients receive; it is essential that quality is understood from patients’ perspective. They pay regard to experiences as much as effectiveness, with safety as a given. Patients want to be treated in environments that are safe and clean; they want to be shown respect and regard, compassion and kindness. The highest clinical quality can be undermined by letting the simple things slip.

“We must have an unwavering, unrelenting, unprecedented focus on quality. Our approach will be dedicated and disciplined, putting quality at the heart of everything that the NHS does.

“We will begin by bringing clarity to quality, ending the daunting and frustrating confusion that is caused by the morass of standards. NICE will be transformed to select the best available standards, fill the gaps and establish a new NHS evidence service that will ensure that best practice readily flows to the front line.

“We can be sure to improve only what we can measure; information can unlock local innovation by showing clinical teams where their greatest opportunities lie. We will create a national quality framework, so that every provider of NHS services systematically measures, analyses and improves its performance. Front-line teams will be supported by a new set of graphically illustrated quality measures, known as clinical dashboards, informing the daily decisions that lead to improvement.

“The power of information will be provided to the public. We will legislate so that all providers of NHS services will be required by law to publish quality accounts just as they publish financial accounts. These will detail the quality of care that they provide for each and every service. Easy-to-understand comparative information will be made available online.

“For the first time, improvements to quality will be recognised and rewarded. Patients’ own assessments of the success of their treatment and the quality of their experiences will have a direct impact on payments. We will harness the expertise and experience of clinicians to raise standards by ensuring strong clinical involvement at every level of the NHS. New medical directors will be appointed to join existing nursing directors in every NHS region. They will be supported by clinical advisory groups to sustain and support the strong clinical voice elevated through the review.

“Nationally, a new quality board will be formed to provide leadership, to give advice to Ministers on top clinical priorities for standard setting and to make an annual report on the state of quality in England compared to international peers. There will be strong safeguards for quality, with no hiding place for those who fail to get the basics right on issues such as infection. I have already announced that the Care Quality Commission will have tough new enforcement powers to tackle infections and other lapses in patient care.

“Finally, we know that healthcare works at the edge of science, constantly creating new ways to cure and care for patients. The NHS has long been a pioneer, but too often too few NHS patients have benefited. We will create an environment where excellence and innovation can flourish. That is why this report heralds new partnerships between the NHS, universities and industry to achieve the very best care for patients. This ambitious agenda to improve quality for patients can succeed only by unlocking the talents of the front line. We will ensure that NHS staff have the freedom to focus on quality, empowering them to improve services.

“Clinicians have abilities that go beyond their clinical practice alone. Our new expectations of professionalism redefine their roles as practitioners, partners and leaders in and of the NHS. We will unlock their creativity and innovation, give greater responsibility for stewardship of resources and proclaim a new obligation to lead change where the evidence shows that it will improve quality.

“These noble objectives will be supported by pragmatic action. Our journey of setting the front line free from central direction will continue. Our commitment to foundation trusts remains strong and we will extend similar freedoms to community services. We will free up their talents by introducing a ‘right to request’ to set up a social enterprise. All primary care trusts will have an obligation to consider these requests, and staff choosing to join such organisations and continuing to care for NHS patients will be able to retain their pensions.

“With greater freedom will come a newly enhanced accountability. The report sets no new targets. Our approach will be openness on the quality of outcomes achieved for patients, meaning accountability for the whole patient pathway from beginning to end. NHS staff are the service’s most precious asset. We will more clearly illuminate how highly we value them by making new pledges to all staff on the constitution, on work and well-being, on learning and development and on involvement and partnership. All NHS organisations will have a statutory duty to have regard to the constitution.

“Furthermore, the system for education and training will be reformed by working in partnership with the professions. We will open a new chapter in our relationship with the medical profession by establishing Medical Education England. We will increase our investment in nurse preceptorships threefold so that newly qualified nurses will be given more time to learn from their senior colleagues. We will pay a higher regard to the contribution of non-clinical staff—the porters, administrators and others who are the backbone of the service—by doubling our investment in apprenticeships and we will strengthen arrangements for learning and development so that all staff have access to the opportunities that they need to update and enhance their skills. Following today’s publication of the final NHS next-stage review report, we will, over the course of this week, be publishing supporting documents setting out in more detail our conclusions for primary and community care, for workforce and for informatics.

“Let me turn to the first NHS constitution. The changes outlined by the review will improve quality, but the best of the NHS—its enduring principles and values, its defining rights and responsibilities—must be protected for generations to come. Patients and the public should be empowered by the clear expression of their rights in relation to the NHS and the value of staff should be fully recognised. Decision-making should be transparent and accountability strengthened. It is right and proper that a national health service funded by national taxation should remain accountable in and to Parliament. These goals are accomplished by our draft constitution, which we will publish for consultation today.

“Our proposal is to legislate so that all NHS bodies and independent and third sector providers of NHS services must take account of the constitution in their decisions and in their actions. The Government will be required to renew the constitution every 10 years, involving the patients who use it, the public who fund it and the staff who work in it. No Government will be able to erode or undo the fundamental basis of the NHS without the consent of the people’s elected representatives. Safe in the knowledge that the best of the NHS shall not perish, we will pursue our ambition to deliver the highest quality care to all, not in some respects, not in many respects, but in all respects. On its 60th anniversary, after a decade of investment, the NHS has the most talented array of staff in its history, united in their ambition. High quality care for all is now within our reach. The report charts a path towards its achievement and I commend it to the House”.

My Lords, that concludes the Statement.

My Lords, on behalf of these Benches perhaps I may first express my thanks to the noble Lord, Lord Darzi, for having repeated this important Statement to the House. I confess that it is a slight surprise to me that, as the Minister commissioned to carry out the next-stage review and to bear prime responsibility for it, he should be repeating the Statement rather than making it on his own account. I am sure I cannot be alone in attaching some significance to that. What we all hoped would emerge above all from this exercise is the noble Lord’s own vision for the future delivery of healthcare in England with the benefit of sound advice from the professions and after the freest possible consultation. We did not want the noble Lord to be in any way hijacked. The fact that the Secretary of State should have appropriated today’s announcement to himself could be indicative of what some of us feared when we read Mr Johnson’s comment in the Guardian earlier this year when he said that he regarded the noble Lord as a tethered goat. The noble Lord deserved better than that. But it is one reason why I suggest to the House that we need to examine this review for evidence of what one might term unwanted departmental influence.

The report which the noble Lord has summarised for us today has been long awaited and will doubtless be pored over in the weeks to come by all with an interest in it. I have not yet had an opportunity to read it, and for that reason it is not possible for me to pass any detailed comment. However, there are surely two tests that the report needs to pass if it is to command acceptance and approval. We need to see that the benefits to patients that it trumpets are genuine and evidence based, and we need to see that its recommendations are achievable, given the inevitable constraints of funding, premises and the numbers of medical and other professionals on the ground.

The noble Lord spoke of this Government having resuscitated the NHS. I should like to think that if he had given this Statement himself, he would not have said that. After 11 years of a Labour Government, he will know that the backdrop to this report is a picture of health outcomes of which this country cannot be proud. For all the additional money poured into the NHS over the last few years, we still have cancer survival rates that are below the European average, high mortality rates from heart disease and stroke, and mortality rates from lung disease that are little short of abysmal. It is therefore strange that we should now suddenly be talking about needing to put quality at the heart of NHS care. The noble Lord spoke of the quality and outcomes framework, but we have seen this year how the QOF was all but neutered by politically driven objectives at the expense of the well considered recommendations of the expert group.

The noble Lord has spoken of putting patients’ wishes first and giving doctors and nurses clinical autonomy. I hope he will forgive me if I say that this line has a familiar ring to it: we have heard it before. He says that change will not be driven by top-down targets. But if that is so, what is to become of the targets that are now in place and that Ministers have so consistently defended? It is no secret that I believe government targets to have had a damaging effect on professional autonomy and morale, and a distorting effect on clinical priorities. They also treat patients as passive recipients of care rather than as empowered individuals. Unless most of these targets can be ditched—and we have not heard that they will be—the noble Lord is unable to say, with any confidence at all, that he is restoring clinical autonomy to the professions.

I welcome the idea of having indicators of quality and patient satisfaction—we have advocated those—but what has become of practice-based commissioning? How do the Government view the role of foundation trusts in the future? What is to happen to payment by results and how is the tariff system to be improved and unbundled so as to remove the barriers to delivering properly costed treatments? These mechanisms were meant to be the engines for improving the quality of care in the health services, but we have heard nothing about them.

The new performance regime published four weeks ago gives strategic health authorities the power to control their areas. That did not have the ring about it of the kind of local autonomy that the noble Lord has spoken of. In his review of the east of England, the noble Lord proposed,

“21 new bodies set up at a regional level”.

Can he look us in the eye and say that this is a locally driven decision? If that kind of approach is to be adopted up and down the country, can he assure us that the risks of establishing further bureaucracy will be avoided?

The Minister has spoken of removing the postcode lottery for medicines. With respect to him, we have heard this innumerable times before. Of course we will support any moves towards greater transparency of decision-making by PCTs—I proposed an amendment to the Health and Social Care Bill last week on exactly that point—but this country is still amongst the slowest to take up new medicines. If local availability of medicines has in the past been constrained by insufficient funding, how can the noble Lord suddenly be so confident that the postcode lottery will be made a thing of the past?

The noble Lord will know the worry that exists about maternity services. The Government say that they are in favour of home births, yet in recent months 15 maternity units have been closed or have lost their obstetric service and 26 more are under threat. If obstetric services are located more remotely than they were before, how can mothers-to-be safely opt for home births? What undertakings can the noble Lord give that his proposals will not lead to super-sizing of maternity units when the evidence shows that the performance of smaller maternity units is, on average, higher than that of larger ones? Here again, the noble Lord speaks of listening to local opinion, but the whole drift of recent announcements and reorganisations has been towards greater centralisation of NHS services.

When the Minister announced the results of his review of the NHS in London, he famously declared that,

“the days of the district general hospital are over”.

Would he like to take this opportunity to expand on that statement in the context of this review? What are the implications of today’s report for the centralisation of GP services in so-called polyclinics? We did not hear that magic word mentioned in the Statement, but the idea, surely, cannot have been abandoned. I have no objection to polyclinics; what I object to is their imposition on communities without consultation. What is the noble Lord’s view of the place of the community hospital in delivering non-acute care in the community? We have not heard anything that gives us even a flavour of how he believes services, both acute and non-acute, should ideally be reconfigured. The Statement is long on generalities but short on specifics.

The Statement referred to workforce planning, but what answers do the Government have to Sir John Tooke’s review? The MMC implementation represented a monumental blow to medical morale and there is apparently no end in sight to the pressures which gave rise to that debacle. What is the Minister’s proposal for resolving that aspect of workforce planning?

Last year the noble Lord, Lord Darzi, accepted an immense challenge when he agreed to undertake the next-stage review. Whether or not every detail of his report commands agreement among parliamentarians, he has fulfilled that challenge—and on that, he deserves our congratulations. He also deserves to have more time with his patients, which I hope he will allow himself to have. We wish him well.

The Minister knows, or should do, that my party does not indulge in opposition simply for the sake of it. We will support him and the Government whenever we think that proposals for the NHS are right and in the interests of patients. As we celebrate the diamond jubilee of the NHS, our reaction to this report is no exception to that principle. Nevertheless, the Minister’s real success or failure will be judged not by what is on the printed page of this report but by the improvement of the health and well-being of the population and the quality of care that patients receive over the years ahead.

My Lords, I, too congratulate the noble Lord, Lord Darzi, on, I think I am right in saying, the first Statement he has ever given to this House and on the completion of a major piece of research. After what must seem like an interminable gestation, he has seen it successfully launched. It is an important report, a review on which, to a great extent, the hopes of patients and the NHS workforce depend.

Sixty years ago that great liberal, Beveridge, brought to fruition his vision for a health service fit for a nation going through great transitions after the War. When the noble Lord’s review was announced, one particular element within the very long terms of reference caught my eye. He set himself the task of working out how a publicly funded, comprehensive, affordable, high quality health service could be delivered on the basis of need, not the ability to pay. It is that laudable aim that we on these Benches support, and it is that criterion against which all other parts of the report have to be judged.

Like the noble Earl, Lord Howe, I have only just received a copy of the report and am not in a position to comment on it in any great detail. As the report has been heavily trailed in the press this week, however, I want to start by dealing with one issue. Ever since 1948 the NHS has been subject to review after review, all of which have attempted to do the same thing: to reconfigure staff resources and patients in order to achieve better health outcomes and to reduce health inequalities. Practically all those reviews have, in the end, come down to one of two things: either a restructuring of the management of the service or a focus on buildings. Coming as he does from a clinical background, and with the support of clinicians across the piece, I hope that the Minister will be able to avoid the trap in which healthcare is essentially evaluated on the basis of buildings.

I notice that he did not talk about polyclinics in his Statement. We on these Benches will also support them only when they are the result of local decision-making by people in areas who have the clinical and resource data to come to the conclusion that the development of a polyclinic will change for the better the health outcomes of their area.

NICE is one of the achievements of which this Government should be most proud. It is one of the most essential parts of any health service. The independence and authority of NICE should never be undermined. I hope that it will be given the resources necessary to implement the speedier approval process, while ensuring that nothing is done to compromise the levels of our research into pharmaceuticals and new medical technologies. I hope also that, whatever decision this House arrives at on co-payments, nothing will be done to compromise the integrity of diagnostic and treatment processes, so that everybody in the country will continue to have access to the highest standards of clinical judgment.

I was interested to see in the report the proposal for an NHS evidence service. We will wish to look at that in greater detail, but if it builds on the system of national service frameworks which we have had for the past 10 years, where best practice is brought together with new knowledge, and provided that it is backed up by sufficient resources, it will be an important development.

The Minister spoke about innovation and the need for us to use the NHS as power to innovate. He then spoke about staff being enabled to set up social enterprises. I am not sure that I agree with those two things going together. The NHS has been responsible in its time for some of the most marvellous innovations. Embryology, for example, has been taken forward in this country unlike in any other. I hope that the Minister in his proposals is not opening the door to increased private provision within the NHS.

I could not help but notice that there was no mention of mental health in the Minister’s Statement, nor was there much mention of long-term conditions or community care; the focus was very much on an acute care system. If noble Lords have any doubt about that, I suggest they look at the photographs in the report, all of which bar one come from acute hospitals. We will not be able to judge the Minister’s proposals in full until we have seen the proposals for primary and community care. That point was made extensively in the report by Sir Derek Wanless in 2002, and we should not ignore it.

The one other question to arise from the Minister’s Statement was money. How will the implementation of the review be funded? To what extent will its implementation be dependent on the sale of NHS property and land?

We welcome an NHS constitution in so far as it brings about concrete guarantees that nobody in this country will in the foreseeable future suffer health poverty. One of the most telling passages of the report on London of the noble Lord, Lord Darzi, was that in which he charted life expectancy at different stages along a Tube line. In so far as the report brings about greater health equality and reduces health poverty, it will have our support.

My Lords, I am grateful to the noble Earl, Lord Howe, and the noble Baroness, Lady Barker, for their response to my Statement. I have been here for 12 months and constantly learn about protocols and rules. I have been told very firmly that there are strict protocols for Statements being made in the Commons first. The House may wish to change the rules. On this occasion, though, I reassure the noble Earl that I have led this piece of work with a team of Ministers, including my right honourable friend the Secretary of State, to whom I am very grateful for giving me all the space. It is not only me; it is important to highlight that this is not the “Darzi report” but the report of 2,000 doctors and nurses across the country, who have led this review at a local level, based on evidence and in partnership with patients and the public as a whole.

The noble Earl raised a number of important questions and issues. First, on quality, why now? As a clinician who works in the health service, I do not want to sound political, but if I take myself back to the day on which I was appointed in 1994, I can remember arriving at St Mary’s Hospital, where I was the only clinician with an interest in bowel surgery. Now I am a member of a team of four other surgeons, two nurse practitioners, one nurse consultant and two stoma nurses. It is important to remember the state of the health service back in those days and where we are at the moment.

You cannot aspire to achieve quality if you do not have the infrastructure. You cannot aspire to achieve quality without an adequate number of doctors and nurses or without the right environment in which to work. This is our opportunity to refocus what the NHS is all about. What energises me in coming to work every day is to improve the quality of care. What patients want when they see me in my clinics on a Friday or a Saturday, at the most vulnerable time in their lives, during sickness, is better-quality care. Earlier I said that quality was not just about the clinical outcomes that clinicians such as me will have an interest in; it is also to do with patient experience. Being here for 12 months, I have had the constant reminder from noble Lords in this House about issues relating to nutrition, respect and dignity. Those are simple factors that are very close to patients, and we need to have a high regard to them in future.

The quality framework that I described is very detailed. We have never had anything like it before. I strongly believe that it is how we will provide the clinicians with the power that they need in improving what matters most—the quality of care. The noble Earl touched on the issue of morbidity and mortality. We have dramatically improved our outcomes and there is clear evidence of that. A recent publication by Sheila Leatherman in her joint publication with the Nuffield Trust clearly highlights this. Mortality following myocardial infarct in this country has dropped by about 42 per cent, which is the highest drop that any country in the world has seen. But I agree with the noble Earl that we can do better. It is not uniform—and the whole purpose of this report is to help clinicians at a local level.

I could not agree more on the question of targets. That is why I made an explicit statement that there will be no more targets. But let us remind ourselves that targets met the aspirations of the patients who used the service. When you double the investment in the health service, you have to have compliance measures in which you can reassure the taxpayer who is funding the system but, more importantly, the users of the service. Let us again remind ourselves that, on the day when I was appointed in 1994, there was no such thing as standards in the NHS. It was a free for all. I decided which patients came in; patients would wait for 18 months and longer and would sleep overnight on trolleys in A&E departments. We had to have targets and hold the provider end of the NHS accountable for the money that it received in relation to patient care. So the targets will become minimum standards—and, as I said in my report, there are no new targets in that report.

It is important to realise that quality can be improved only at a local level. I have been here for 12 months on a part-time basis, and I reassure the House that no one in Whitehall alone can decide how to improve quality at a local level, or help to do so. Quality needs engagement of staff at a local level, and that is what the report has done. The spirit of the review over the past 12 months has been all about empowering clinicians locally to design models of care based on patient pathways, starting from birth and finishing off with end of life.

I am sure that, once the noble Earl reads the report, he will appreciate that all sorts of other policy themes will address the many good questions put to me about, for example, more foundation trusts—on which I could not agree more. We will be working with Monitor and others to both reinforce what we have been doing over the past 10 years and to have more providers obtaining foundation status. We are also extending that to the community services. This Government introduced the NHS tariff, and we will be working further on it by introducing a normative tariff, paying for the highest quality of care.

There is a lot in the document about practice-based commissioning, and how we free up staff at a primary community level using the practice-based commissioning escalator. On the postcode lottery, we are attempting to expedite the approval of NICE drugs, which now takes on average 18 months to two years and will in future take between three and six months. In addition, the noble Earl referred to our more transparent process, in which PCTs could still approve the use of drugs which have not yet received NICE approval.

I turn to maternity services; the noble Baroness, Lady Barker, also raised mental health and long-term conditions. There are 10 regional reports, each of which has a pathway on maternity services, mental health and long-term conditions. I would be delighted to send the noble Baroness copies, because they highlight local aspirations of how these services should be reported. The noble Earl also raised the future of maternity services. The best people to decide the future of maternity services are local clinicians working on the front line, in consultation with the public and patients. In the future, no one in Whitehall should be in any way involved in this decision-making. That has been the Government’s policy over the past couple of years, and it will be our policy in the coming decade.

I have not mentioned my favourite word: polyclinics. “Polyclinic” was a description of primary community services in London. I was fortunate and privileged enough to work with many clinicians in London. When I did that report, I was a clinician working in London; it was a response to the aspirations of Londoners with regard to improving primary and community services. Since joining your Lordships’ House, it has become clear to me that decisions on the implementation of polyclinics are a local issue. Noble Lords are aware that local consultations with Londoners were carried out for six months. We have made no announcements on further investment in primary and community strategy since the interim report published in October, highlighting 115 new health centres, which we have debated in this House on many occasions. We must increase capacity in primary and community services to meet challenges facing the health service now and in the future.

I remind your Lordships that the life expectancy of a person living in Manchester could be 10 years shorter than the life expectancy of someone living in some parts of London. We must invest more in primary and community strategy because primary and community services have the biggest impact on survival rates and the health of the nation. We also want patients to have more choice in them.

Workforce education and training is another significant area that we have debated in this House. I remember our debate on modernising medical careers, and the dilemmas we have had following the introduction of MMC. I reassure the House and the noble Earl that I have been working with not just the profession and its leaders but with John Tooke himself in designing the workforce planning and education. The relevant document was published today and contains a letter from him, which warmly received the contributions that the next stage review has made, including the creation of Medical Education England.

More importantly, I was asked in the House about the need for greater transparency with regard to funding arrangements. I am delighted to tell the House that we are introducing a tariff system whereby the money will follow a trainee. That is in addition to the other announcements that I made.

The noble Baroness, Lady Barker, asked about innovation. There will be innovation funds at a local level, which is very different from social enterprise. Social enterprise is one way in which staff could be freed up in the future to enhance community services, but we have innovation funds to the tune of £100 million, which clinicians and others will be able to access to make innovation part of everyday working life.

My Lords, as a relative newcomer to the House, I apologise if I have not followed the protocol for intervening in discussion on a Statement. Like many of your Lordships, I was a “baby-boomer” born after the Second World War and have lived through this incredible period of unprecedented and unparalleled healthcare, which is one of the marks of a truly civilised society. Like many people in their sixties, I feel the need for something of a retread. Therefore, I entirely welcome the review and am very grateful for what has been reported to us of it. I have only just received it and have not had a chance to read it in detail. However, I wish to raise two concerns about the Statement and the Minister’s comments.

First, I welcome the Minister’s comments on nutrition, respect and dignity and the references to wider health teams in the context of the promotion of health. The church and members of all faith communities in this country will welcome the reference to wider health teams but will regret the lack of an explicit mention of chaplaincy as part of that. Physical and mental health can be seen only in the context of the wider human and social health of individuals, everything that goes to make up spiritual health. I hope that the next next stage will contain much more explicit recognition of the need to make statutory provision for chaplaincy and not treat it just as a bolt-on or occasional or optional extra.

Secondly, I appreciate the Minister’s reference to bringing down levels of morbidity and mortality. However, the ability to remove death altogether has escaped this Government, and, I suspect will escape all Governments. Death remains the end of life. I appreciate very much the several occasions on which the noble Lord referred to patient pathways from the beginning to the end of life. However, if I am not mistaken, hitherto the one area in which the National Health Service has not been required to demonstrate achievable outcomes in terms of patient experience is the end of life. It seems to me that the way in which we honour and try to set standards for palliative and terminal care is hugely important, and that that should at least be commensurate with what we do throughout people’s lives. The hospice movement is one of the glories—albeit all too often it is rather marginalised from the National Health Service—of our health provision, and needs our support desperately. I hope that further attention can be given to that matter.

I have had a chance to look briefly at the report. Paragraph 70 refers to the need for a service that,

“not only ‘adds years to life’, but also ‘adds life to years’”.

That adequately covers both my points.

My Lords, I am grateful to the right reverend Prelate for the points that he raised. As regards long-term conditions, I am grateful for the support for our plans to meet the challenges of the future. As I said, one of the great successes of the NHS is converting acute illnesses into long-term conditions. Therefore, we are living longer and we need to have a strategy to deal not only with the ageing population but patients with long-term conditions. I could not agree more with the comments about chaplaincies. That is the subject of the social care Green Paper. I recognise the major role that chaplaincies play in the provision of health and social care. I repeat that the 10 regions discussed an end-of-life pathway. The thematic conclusion was that care needs to be more integrated in that pathway. It is probably the one pathway that we will all go through, and health and social care need to be co-ordinated around the needs of patients, and more importantly of their families, to ensure that patients die in their home environment with their family and loved ones.

My Lords, I welcome the Minister’s report today and congratulate him on having reinvigorated positive attitudes to and respect for patients throughout the NHS. Will he explain how the new bodies, NHS Medical Education England and the NHS evidence service, both of which I warmly welcome, will ensure that patients understand the importance of research as a way of providing an increased information database so that they can take sound decisions about purchasing drugs and so on in the future, and so that they understand that researchers are benefiting care and patients are not guinea pigs for the NHS? Does the noble Lord intend to do anything to decrease bureaucracy for those undertaking research evaluation projects?

My Lords, I am grateful to the noble Baroness for her question. I am delighted that NHS Medical Education England and the NHS evidence service have been welcomed. We have a lot to say about research in the constitution: what the patients’ responsibilities are in regard to it and how important it is. As I said earlier, we need to exploit some of the innovations that we have seen in the NHS and, more importantly, to see how we can translate our excellence in science and technology in this country to the benefit of patient care.

My Lords, I too thank the Minister for repeating the Statement. Everyone knows that it is his report, and we do not need to worry about where it was spoken about first. When the papers referred to a tethered goat, his name was not mentioned. However, I assure him that we all know that he is not a goat. I have known him for years, and I know that you cannot tether Ara Darzi.

I welcome the report’s emphasis on quality and standards. However, I have many questions, and an appropriate time should be allocated for a long debate on the report rather than the one hour that we will get today. A quality board will be established, with top priorities for standard-setting. NICE will be asked to produce standards, but it is not clear whether it will set clinical standards. The priorities identified for the quality board, and therefore for Ministers, will be care standards. There are differences between the two, which I know the Minister understands. Although I welcome the establishment of clinical dashboards, they are good for improving clinical care only if the deficiencies identified are met with the necessary resources. Will the Minister say whether they will be?

Lastly, how will the universities be involved in improving the quality of care? I welcome that suggestion.

My Lords, I am grateful to the noble Lord for his points. I shall be brief. First, the National Quality Board will advise NICE on setting standards, which include both minimum standards and clinical standards. We are well aware that NICE works with professional bodies to set clinical standards, but it will have an additional role in kite-marking some of the standards that professional bodies, such as royal colleges, already have.

On the dashboards, we will provide the tools by which we will measure how we empower patients. I referred to measurements by which we will empower patients. Measurements are also extremely important in allowing clinicians like us to improve services. These are dynamic measurements, and we will provide the tools and the clinical team to make this happen.

I believe, for several reasons, one of which being that I work at a university, that the university leadership could be exploited to improve patient care. The universities will have two roles to play. First, they will be part of health innovation and education clusters, providing leadership in education and training. Secondly, they will have a leadership role in innovation in health and social care.

My Lords, since the National Health Service was established, there have been changes in the devolved nature of the Administrations. Although these are welcomed, what arrangements are there for this new, next stage of reform for England to be made known to and possibly introduced in Wales? We do not want to miss out. Would Scotland also be included?

Secondly, for generations, people with neurological diseases and so on in north and mid-Wales have gone to Liverpool; they have crossed the border. Now there is some introduction of a scheme whereby people from north Wales travel not for an hour to Liverpool but for five hours to Cardiff or Swansea. Also, people from mid-Wales go to the Shrewsbury hospitals. What guidelines will the Minister have for those cross-border issues raised, as well as the devolved issues?

My Lords, I thought that my brief was big, but I never thought that I would be dealing with a devolved Administration. However, I reassure the noble Lord that, since the publication of the report, the department has talked to the devolved Administrations to answer at least some of the questions raised—most importantly those about cross-border issues, but also those about workforce planning, education and training. We train and educate doctors and nurses in this country within the five regions, and it is important that we have a strategy in which we bring England, Wales, Scotland and Northern Ireland together in deciding some of the major themes. The devolved Administrations are looking into that.

My Lords, in relation to what the Minister just said about talking to the devolved Administrations, is the constitution that we are told about in the report one for the National Health Service of the United Kingdom or one for that in England? It talks about empowering patients. Patients do not need empowering; they need treatment, understanding and respect. What exactly is the constitution and who is it for?

My Lords, the constitution is for the NHS in England, not the NHS elsewhere. However, as I said earlier, we are talking to our colleagues in Wales and Scotland in relation to it. The content of the constitution is out for consultation today, for 14 weeks. I would be grateful if the noble Baroness contributed to that consultation.

My Lords, I join others in congratulating the Minister on producing a magnificent manifesto, in a sense, for the health service for the next decade.

My first question is on the further information that will be made available for us. I would like to be assured that targets will not disappear completely. As one who uses the National Health Service and does not have private medical insurance so that I can go through the service quickly, I worry greatly that we may slip back to waiting longer for treatment, as we did in the past. It is 10 years since I had cancer, and I knew many people who died then because they did not get treatment as quickly as they should have done. Their cancers moved into different parts of the body; had they had early treatment, they would have avoided those illnesses and subsequent death. I would like some clearer statements from the Government on where we stand on targets because, notwithstanding what is alleged politically about targets, many people feel that they have delivered a great deal and would be reluctant to see them disappear without the knowledge that there will not be any backward movement to longer waiting for different types of treatment.

According to the Daily Telegraph, 1.25 million people have signed up to oppose changes in GP practices. Is the Minister aware from his researches that many people around the country are unhappy with services from their GP practices in a number of respects? He said that there would be better rewards; we are all aware that there have been substantial improvements in the rewards given to GPs in recent years. As part of this openness and greater information and to ensure that we are getting improvements in GP services, will he commit himself and the department to make public at each level the salaries paid to all GPs around the country?

My Lords, I want to reassure my noble friend that minimum standards, which we previously described as targets, will remain, including not only the four-hour wait in A&E but the 18 weeks. Interestingly, many of the regional reports have challenged themselves to further reduce these targets below four hours and 18 weeks. Many services across the country provide services within nine weeks, and the south-west region has a two-hour A&E target rather than four. However, the national standard is four. Information on GP practices will be available. All service providers, whether of acute or primary care, will have to publish the quality measures and, more importantly, information on patient experience and outcomes.

I think that information on salaries is already in the public domain. I am sure that my noble friend is aware that my salary is published as are those of many of my GP colleagues.

My Lords, I add my considerable gratitude to the Minister for his report, which has very many strong features. He mentioned the mental health pathways in the regional reports. Is there anything in his national review about the need to give greater priority to the quality of service and level of safety in psychiatric in-patient units? If there is no such emphasis on a priority in this area, we will continue to have wards where patients and staff are living and working at risk.

My Lords, the 10 regional reports address the mental health pathways in 10 different regions. In some, they have addressed the issue and certainly challenged themselves on safety. I really want to stress that it is an enabling report. It is not a report that I have designed in Whitehall; it is one that I have built on in consultation with 2,000 clinicians across the country about the tools they need to make this happen.

Safety is a feature of the report, and we are introducing two schemes. The first is “never events”, which will be introduced next year and within which we believe the NHS will not tolerate certain things. The type of events covered still need to be decided. The second is the national patient safety campaign, which covers areas of catheter infection. At a local level, clinicians have challenged themselves under the mental health pathways in addressing safety issues in high-security mental health environments.

My Lords, like other noble Lords, I welcome the Statement and the report. The report is a good one and will tackle many of the problems. I had a particular note about the paragraph on page 4 that states:

“Patients want to be treated in environments that are safe and clean; to be shown respect and regard, compassion and kindness. The highest clinical quality can be undermined by letting the simple things slip”.

The noble Lord may recall that earlier this year I raised with him the question of mixed-sex wards and asked him when they would be phased out, as was promised. He said that the task was impossible at that time. Was the matter given further attention in this review? Can we expect to have a change in government policy that will phase out mixed-sex wards?

My Lords, in the debate that we had then, when the confusion was all about definitions and terminology, I was referring to mixed-sex accommodation. This Government are committed to ensuring the provision of single-sex accommodation and single-sex bays. That will be one of the parameters that we measure as part of patient experience.

My Lords, does the noble Lord accept that quality at a local level depends on the context of the local level? One thing that the founding fathers of the NHS would be surprised at today is the disparity of provision in some of our most deprived communities, which suffer from financial, social and health inequalities. Can anything in his report give the House some succour by suggesting that future targeting in these areas will efficiently tackle some of the deprivation?

My Lords, I am grateful for the noble Lord’s intervention. My report addresses the inequalities that exist in health and healthcare, and the interim report also says that we need nationally targeted campaigns to deal with some of those inequalities. The noble Lord will be aware that the October report referred not only to health centres but to the fact that we are investing £100 million in the creation of new primary care centres in areas where inequalities are most challenging.