asked Her Majesty’s Government whether specialist hospital units have an obligation of ongoing care towards their patients when a clinical crisis occurs.

The noble Baroness said: My Lords, I am glad to have this debate in the week that celebrates the diamond birthday of the NHS. Indeed, I believe that the NHS is a glittering diamond today. Sixty years ago, a visit to the doctor would have cost you half a crown. At the end of the day, the GP’s pocket would jingle with the change slipped into it by patients. The visit was expensive and, in return, the GP could do remarkably little; it was really supportive care. Just before the NHS began, penicillin had become available in the community and was a revolution in patient care. My mother-in-law first gave penicillin to a patient in 1946. This very ill, frail patient made a dramatic recovery. The teapot that she gave my in-laws as a wedding present is still in use today, and we call it the penicillin teapot.

Now we have much more than penicillin. We have complex treatments that are life prolonging, with complex side effects and risks. Now patients live actively with their disease for many years.

Data from 2006 in regard to acute beds per million across the 27 European Union countries show about half the number of beds in the UK compared to France, Germany, Austria, Finland and others, with only Spain and Cyprus having fewer beds than us, or just about the same number. At the same time, there are increasing pressures on our acute beds when patients become ill, and no one should underestimate that when patients living with a complex disease develop another condition, their pre-existing co-morbidity can make their management very complex.

The General Medical Council is clear that doctors have a duty of ongoing care. Indeed, its document Good Medical Practice states that the doctor must:

“Make the care of your patients your first concern”.

It goes on to state that a doctor must provide a good standard of practice and care, particularly recognising and working within the limits of professional competence and working with colleagues in ways that best serve patients’ interests.

Of course, you do not know what you do not know, and here is the problem. It becomes increasingly hard for clinicians in a general service to know about the complexities and intricacies of many of the drug treatments or potential interventions for patients with complex conditions. Providing continuity of care is an enormous challenge, particularly as general practitioners no longer do their own out-of-hours care. Whoever sees a patient to admit them to hospital, or treats them at home out of hours, almost certainly has never seen the patient before. NHS Direct assures me that the patient’s record is available when the patient calls subsequently, but, of course, that is only the record of the previous telephone call; it does not have access to the whole clinical record. This telephone picture does not include examining a patient or seeing the clinical change in their overall appearance.

Indeed, I expect the Minister will have had the same experience as I had. A clinical scenario described over the telephone sometimes seems to bear remarkably little relationship to what you find when you go to see that patient, wherever they are. Indeed, patients can look remarkably different when they are at home from when they are in a hospital bed simply because they are in a different environment. Some services, particularly those for patients with rare conditions, have handled this well and are exemplars of good practice. The Royal Marsden has a triage system run 24/7 by expert cancer nurses, who will stay in touch if the patient is referred to their nearest accident and emergency department.

Moorfields Hospital also has a telephone advice line for patients, and the medical director tells me that no one has been turned away for capacity reasons in his six years there. Great Ormond Street Hospital is a tertiary care provider with an ongoing obligation of care to patients for whom it is directly responsible, but often patients treated in secondary or primary care are also patients at Great Ormond Street. Staff there describe themselves as having to be “flexible” with beds and ward space to meet their responsibilities to the patients they know. The Royal Brompton and Harefield Hospital runs the heart transplant unit and offers a 24/7 clinical advisory service for all its patients, which patients use very effectively. It is worth remembering that these patients may live far to the north or on the tip of Cornwall. Other services give patients a credit card sized card with details so the treating team knows who to contact.

My own service studied patient-held records some years ago, but we found that the clinicians did not fill them in because that seemed to duplicate work. The theory did not match up to our expectations, and we abandoned patient-held records.

The difficulty is not with heart transplant patients, for example, who are in a very small population, but with those in larger populations where a lot of patients now live well and for a long time, although at an increased risk of intercurrent illness. Cancer patients are a classic group. If they get admitted it is important that the details are known about their condition, whether they are currently in a clinical trial or not and what the expectations are from their ongoing treatment. Another group is neurological patients with communication difficulties, who may get admitted to a unit where the nursing staff admitting them are just not adequately trained in managing people with complex communication difficulties. To return to cancer patients, though, the pointers that used to be present no longer exist. Many patients with metastatic disease are now doing well on treatment, so the presence or absence of metastases is a poor prognostic pointer.

The Sherwood Forest hospital trust has developed an exciting, innovative system to try to cope with the problem of where its patients get admitted to. Its recurring admissions patient alert, commonly known as RAPA, works by sending an e-mail alert whenever a patient is admitted to hospital through accident and emergency or acute admissions. The clinical nurse specialist allocated as the patient’s key worker is sent an e-mail to her BlackBerry, as is the doctor. That means there is immediate attention and streamlined care, improving efficiency and allowing patients to be discharged earlier. In the past, patients might have languished for days before anyone thought to inform their cancer specialist that they were in hospital.

The values of the NHS are outlined in the consultation document on the NHS constitution. They are about respect and dignity; the value of each person; a commitment to quality of care; compassion, particularly finding time to listen; about improving lives; and, I note particularly, working together for patients. There is a final value: that everyone counts. As the Minister rolls out his changes for the NHS, I make a plea that he embeds a duty of ongoing care as a quality marker within clinical service contracts. There is no reason that a clinician cannot be invited into another trust to see a patient that he or she already knows. Such a visit can provide important continuity of care and inform appropriate decision-making. Where difficult decisions have to be made, it becomes particularly helpful for the patient to be seen by someone who knows the details. There is no substitute for eyeballing and examining a patient.

There are real dangers that clinicians can be inappropriately pessimistic, abandoning treatment too early, or inappropriately optimistic and zealous. When a patient’s complexities and previously expressed wishes are known, comfort care, rather than intensive resuscitation, may be more appropriate. There has been much in the press about patients being kept alive longer than they wanted to be, but it is rare that medicine does that. The main danger is that patients are given up on inappropriately early, or just not treated as well as they might be, because they are under a clinical team that knows neither the patient nor the complexity of their condition and the subtleties of its treatment.

The ongoing provision of potential support requires an infrastructure investment and an attitude by management that recognises the same duty of care as the GMC expects of doctors. It cannot be paid for as a separate item, but needs to be built into contracts as a quality marker and audited. That way we can stop patients falling through the net in a world where care has become increasingly fragmented, both through its complexity and through the change in working hours and work patterns of clinicians.

My Lords, I thank the noble Baroness, Lady Finlay, for this important dinner-break debate. I also thank the Minister for her half-announcement, and feel I should explain. Around this time of night my stats begin to drop—that means my oxygen levels start to decrease—and I felt that should I get halfway through my speech and start going blue, I did not want the noble Lord, Lord Darzi, to have to resuscitate me. So I asked for permission for my noble friend Lady Finlay to fill in while I recovered, and that was agreed. I thank the House for that reasonable accommodation, although I seem to be getting through a lot since I arrived.

Specialist hospital units are of particular importance to me and other severely disabled people, and I support their having an obligation of ongoing care towards their patients when a clinical crisis occurs, whenever possible—although it would not always be possible. More disabled children and adults now live longer with complex conditions. We need specific expert medical services in order to literally stay alive, to be healthy and to be active. Specialised hospital units play an essential part in that equation. Speaking personally, the Lane Fox specialist respiratory unit in St Thomas’s Hospital is a vital component of my health, safety and happiness.

I have experienced the best of times and the worst of times at the hands of the NHS. When I was born, doctors told my mother to take me home and enjoy me because I would not live the year out. At 49 years old I am still defying that prediction. Over the years my survival has depended upon many wonderful healthcare interventions, but particularly the interventions from specialist hospital units.

I am lucky to be a patient of the unit at St Thomas’s. It provides highly specialised care for patients throughout the United Kingdom who have severe breathing difficulties due to accident, illness or, like me, neuromuscular disease. The unit supports more than 650 ventilated patients at home through outreach programmes, telephone advice and, the most important feature, in-patient care when seriously ill—if, and only if, a bed is available. In my case, only once in 10 years have I had to wait 24 hours for a bed to become free.

The unit knows that the local general hospital is unlikely to have the knowledge or equipment to intervene in the time and manner necessary to ensure survival. Only four years ago I unfortunately found myself in A&E in a local hospital, where my husband had to negotiate extremely hard to get them to agree to resuscitate me if I should go into respiratory failure. I was lucky; I happen to know people in the Department of Health, and a video of my experience was made and shown to every chair and chief executive in the NHS. But it should not have been so.

In addition, the unit at St. Thomas’s is the principal centre for advice to the UK’s 30,000 polio survivors. Its holistic management programme includes respiratory, orthopaedic and pain management consultants. The Lane Fox unit is unique, not just for its clinical expertise but, equally, it celebrates disabled people’s lives. It understands that patients are far more than their diagnosis; it recognises the need for treatment to fit in with the demands of life, rather than the other way round, however severe your condition.

Dr Geoffrey Spencer, who developed the unit in the 1960s, pioneered the use of home ventilation. He even went as far as to organise trips abroad for people in iron lungs—totally contrary to every health and safety rule in the book. He believed in the expertise of the patient. The unit has gone on to develop a strong patients’ association, which has had profound influence over its design and nursing practice over the years. In addition, the association has raised more than £2 million since 1984, a testament to patients’ confidence in the unit and the collaboration that they have sought with the health clinicians.

Today the design of the unit and its facilities are completely disability-friendly. It includes wheelchair-accessible showers and a place for PAs to stay when they are needed. The unit is led by Dr Craig Davidson and ward manager Natalie Grey. They and their teams are totally committed to supporting profoundly disabled people to participate actively in society. Theirs is the hallmark that our National Health Service must perpetuate if all patients are to be regarded as having equal value.

Without this specialist centre, I know that I would not be with you now. It enables patients like me to feel safe and confident and to live life to the full. Most importantly, when we are in crisis, we know we will live through it because of the expertise mixed with the knowledge of who and what we are.

My Lords, my noble friend Lady Finlay has once again asked a Question which gets to the heart of quality and health systems. Indeed, this debate is about the quality of the health system itself; it is about continuity and the co-ordination of care. Professor Don Berwick, an American, spoke movingly about the NHS at last week’s celebrations. In asking himself what he wanted in an American system, he cited several examples from the NHS. He said, “What I would really like is a system which remembers me”. He did not want a fragmented system. Those seem very wise words.

I speak not with the first-hand experience of the patient, nor the second-hand experience of the clinician—if I may put it that way, with clinicians in the Chamber—but with the third-hand experience of having been responsible for policy and for the management of health services. I want to bring a policy perspective to the debate.

I want to highlight two examples which draw out some of the detail. The first concerns the London Lupus Centre. I spoke recently to Professor Graham Hughes, who runs this specialist centre, serving a special group of patients, and asked how he dealt with this sort of problem. He said that staff keep in touch with their patients and get about three or four calls daily from clinicians asking for advice and help regarding patients who have been admitted to other hospitals. He said that in general they dealt with the clinicians directly over the telephone and that only in the rarest cases did they bring people back to their service.

The message from this service seems to be that its patients were well informed and understood their condition. The London Lupus Centre clearly believes that this is part of its responsibility. I asked Professor Hughes whether he expected anyone to put this in contracts or take payment for it and he said no, it was just part of the arrangements. Interestingly, he was also very sensitive to the feelings and behaviour of the clinicians in the general hospital who were treating his patients. Sometimes specialist centres are the right place, and sometimes they seem almost to wash their hands of patients who are elsewhere. Occasionally, it is the other way round, and specialist centres try to hang on to people too much. Somewhere, there is a balance. The lupus centre has a good, balanced, common-sense approach, with the focus very much on the patient’s individual needs. There is a dialogue; it is a system which “remembered me”.

Let me turn to the mental health system, which is much more complex. I am indebted to a discussion with Professor Rachel Jenkins of the Institute of Psychiatry. There is much more danger of fragmentation: people cared for in specialist mental health units may become physically ill and need to be cared for elsewhere. Similarly, people in units who have a physical illness may need mental health treatment. There is much more moving around, with many more people and a much wider range of specialities involved in such discussions. There are also problems in mental health units with people recognising the physical or, in more acute hospitals, the mental health condition that is involved. There are many more difficult issues.

What are the policy options open to Government? There is one thing that happens in mental health that may have wider relevance—the case management of patients who have a recognised diagnosis and condition. There are people who are responsible for managing across the gaps and making sure that care is provided in the whole range of settings, whether there are physical or psychological needs. There are other mechanisms; after all, GPs can do this to some extent. With regard to maternity care, women in most services carry their own notes and provide a level of continuity themselves. There is the development of care pathways in various areas.

As a former chief executive of the NHS, I probably know better than anyone how very difficult and inappropriate it often is to be prescriptive from the centre. So what policy options are available? There are models, some of which I have mentioned, for securing better co-ordination in continuity of care. In NHS institutions or organisations working as part of the NHS delivery of service, there should be reasonable expectations of partnerships and of the behaviour of clinicians. Specialist units should not wash their hands of people once they have left their door, but neither should they hang on to people for too long. There should be a balance, with continuity of care and liaison between everyone involved.

How does the Minister envisage that world-class commissioning will make progress in ensuring that these visions of continuity and co-ordination of care will take place in the NHS? What means are there for doing that? Is this about making sure that good examples, some of which we have heard of tonight, are recognised? I am reminded by the speech of my noble friend Lady Campbell that I was the chief executive who arranged for that video to be shown to chairs and chief executives. I appreciate that there is at least one chair in the Chamber; chairs and chief executives are not normally moved to tears, but people were deeply impressed by that example of what a health service can be like when it is wonderful and remembers you, and what it can be like when it does not.

What can the Minister do to make sure that those models are adopted? He cannot do it by mandating, because it is at much too detailed a level. Can he do it by example? Can he incentivise? To use the new language that I understand is around at the moment, can he help nudge the commissioners in the direction of ensuring that the services that they commission provide this level of continuity and co-ordination? Will he encourage them to recognise that specialist units have a vital role and that they can operate only by having a good relationship with the more general units that surround them? Will he ensure that commissioning makes sure that this is a system which “remembers me”?

My Lords, I thank my noble friend Lady Finlay of Llandaff for asking this vital Question. I have to declare an interest as life president of the Spinal Injuries Association. Many of our members are worried that they might not be able to be admitted to a spinal unit which knows them, knows how to nurse them and has their clinical notes when a crisis occurs. I have been treated in a spinal unit.

I give as an example an accident that happened to me. I was pulled out of my wheelchair at the parliamentary dog show in 2000 by my Great Dane, which was protecting me from a pug dog, and I fractured both legs. I was admitted to the Chelsea and Westminster Hospital with five fractures, three in the right leg and two in the left. The wrong plasters were put on the wrong legs and were not cut in half as they should have been for an inspection of pressure due to no feeling. Before long, I felt growing problems. I was running a temperature and suffering spasms. When I had to do a manual evacuation, as paraplegics have to do, obtaining two glycerine suppositories was like getting blood out of a stone.

With the assistance of my girl helper, whom I had to call, I succeeded in evacuating in bed, but the procedure took so long that lunch had arrived before I had finished. It was not very satisfactory, especially as it was a mixed ward. The registrar told me that he did not agree with the views of the consultant. How right he was. I was lucky enough to be able to be transferred to Stoke Mandeville spinal unit after a week. When the plasters were taken off, I had two black heels with pressure sores, which took a year to heal. I had an operation for external fixators on both legs, which had to remain for about five months. I stayed in the spinal unit for a few weeks before going home to Yorkshire, where I received periodic help from the local hospital. But the crisis was over. It could have become a life-threatening clinical crisis if I had not had the correct treatment and nursing in a spinal unit. Doctor Guttmann, medical director and founder of the spinal unit at Stoke Mandeville Hospital, always told patients that if they got into medical difficulties they could go back to the unit and receive the special care that they needed.

This debate arose out of the tragic death of my late noble friend Lady Darcy de Knayth. Before Christmas, she was concerned because she was coughing up a little blood periodically. She was found to be anaemic and was given two pints of blood. I was very concerned that she had blood without a diagnosis. Davina had been waiting to go to her local spinal unit at Stoke Mandeville, but had two appointments cancelled. As I was very worried about her, I went to the Minister, the noble Lord, Lord Darzi, who said that she could go to St Mary’s, Paddington, to be diagnosed. I thought that that was an excellent suggestion and told her so. When Davina went to her GP, he said, “I am in charge of your case”. What happened to patient choice?

After Christmas, she told me that it was thought that there was something wrong with her bone marrow. I again tried to persuade her to go to St Mary’s. She was still waiting for the spinal unit. When my husband got into severe difficulties in Yorkshire, I was able to take him to St Mary’s, which diagnosed a problem and helped immensely.

During the parliamentary Recess, I was telephoned to be told that Davina had had a seizure and had been admitted to her local general hospital against her wish. The paramedic in the ambulance, her physiotherapist and her GP all thought that she should go to the spinal unit, but they were told that there was no bed. Davina relied on the safety net of being able to go to a place that she knew and where they knew her, but she was denied it when she was at her most vulnerable.

At Wexham Park Hospital, there was no suitable mattress or bed. She spent six hours in A&E and sat on her Roho cushion for 24 hours in fear of getting a pressure sore until a mattress and bed were hired. Davina was convinced that she had autonomic dysreflexia, which may occur in quadriplegics and paraplegics whose spinal cord lesions are above the level of T6. Wexham Park had never heard of it. I was in telephone contact with her children, who were becoming desperate. At that point, I thought that the only person who could help was Professor Mathias, an expert in autonomic dysreflexia who had done research at Stoke Mandeville. He was going to see her on the Sunday, but Davina died at 1 am.

If only Davina had gone to the spinal unit, she and the family would at least have been spared such stress as they had. The family had a private post-mortem undertaken and Davina’s notes were sent to them by Wexham Park and the GP within a few days, but her son, who was next of kin and executor, is still waiting for the notes from Stoke Mandeville. This is just adding to the stress of an unfortunate situation.

The Darzi report stresses that patients should have choice and good quality of care. That is admirable. However, while there are many specialised units which deal with all kinds of patients with very rare conditions, they operate on a supra-regional or national basis. They are often flooded with patients, and some beds are blocked because of home circumstances. How will treatment be provided if there are not enough beds and a crisis occurs? That can be the only lifeline that such patients have. I hope that the Minister will take up the challenge and do his best for these specialised units and the patients who depend on them.

My Lords, in this period when the NHS is quite rightly celebrating its 60th birthday, it is good to have an opportunity—I thank the noble Baroness, Lady Finlay, for providing it—to reflect back over those 60 years, of which the staff of the NHS can be immensely proud. We also have the Minister’s review to look forward to. This issue of specialist services in the NHS is a very apposite one.

I suspect that one thing that has not changed in all the 60 years of the NHS is that, if you really want to know what is going on, you ask the porters. I say that because last year a very good friend of mine was being wheeled in to have an operation in her district general hospital and the porter said to her, “I don’t know what you’ve got, love, but it’s something really special—they’re all in here with cameras and everything”. He was dead right; his diagnosis was spot-on. She had a one in a million condition, which was being operated on, and the results of that would not only be the pride and joy of the surgeon’s career but would be beamed round the world to help other people.

The noble Lord, Lord Crisp, is absolutely right. We have one of the biggest and most complex organisations in the world, with massive potential to do good. The key thing about it is that we still search for the best systems. Looking back on the NHS over 60 years, when it started the equipment that people had to use was largely static and could not be moved. Travel was tremendously expensive, yet people went great distances to access some of the revolutionary care that was, at that point, free to them for the first time. Nowadays, equipment is highly portable and we have the internet through which diagnostics can be shared very easily, and so on. Communication is much easier, yet we still have not cracked that thing that the NHS has always tried to do—to get the patients to the right clinicians in the fastest possible time. Much of that is what the Minister’s review continues to be about.

One reason for that problem is that urgent care clinical pathways are complicated and blocked. On the reasons why they are blocked, one of the most difficult things, which gets in the way of specialists and specialist care, is that out-of-hours services are so diffuse and difficult to get to that people still continue to present in A&E when they should not. They still continue to go there, because they do not know where else to go. A key thing about getting specialist units working well with the right patients in the right way is to make sure that people who go to A&E do so for the right reasons and are then got quickly through to those who need to see them. An issue that goes alongside that is that access to rapid treatment pathways similarly gets clogged up. The Minister’s review has talked a lot about getting people rapidly into stroke units. To be able to do that we need to make sure that access points are clear and clearly understood. Now, 60 years on, one thing that we should be looking at is standardisation of out-of-hours access to acute and diagnostic services. If we could achieve that, we could make things go well.

Furthermore, if we are to ensure that patient pathways are clear, we need perhaps for the first time to recognise that the complexity of where staff are deployed has a direct bearing on whether those pathways work. It is infinitely more complex now; staff tend less and less to be stationed in one institution. We need to look again at the role of telemedicine and things such as CT scan interpretation to enable clinicians to ensure that they can cover different institutions. Perhaps more than that, we need to develop new protocols, which enable specialist staff to work and to advise colleagues across a range of institutions. A&E and trauma units depend on having a mix of specialists very close at hand to advise on complexities. If we are to fulfil the Minister’s vision of ensuring that patients get to specialists much more quickly than they ever have before, we will have to ensure that those specialists can work and advise away from their base units. We do not yet have the protocols in place to ensure that that can happen across different trusts.

One final thing that we need to do is to redefine the role of community hospitals. Rehabilitation also needs to change to free up space in specialist units. People like community hospitals; it is one of the great testaments to those hospitals that many of them predate the NHS and have stayed, despite every NHS review that has ever taken place. The trouble is that, much though people like them and the very local presence of the NHS, their role is ill defined. I suspect that if for the next 60 years we have the high-tech systems that clinicians need and want to access patients much more quickly, we will have to give the public a local point of access which they trust will enable them to go forward into those specialist units very quickly. I hope that the noble Lord, Lord Darzi, can work on those protocols for the next 60 years, as that will improve patient care.

My Lords, in preparing for this debate, I was trying to second-guess the problem that it sought to address. In her speech, the noble Baroness, Lady Finlay, widened the debate beyond what one might have expected from its title. I do not think that there is anything wrong with that.

As someone who has been involved as a non-executive director in the health service over innumerable reforms, I wondered initially where everything had gone so wrong that a specialist hospital would not have responsibility for patients who it had under its care. I declare a small interest. The noble Baroness, Lady Masham, mentioned St Mary’s Hospital. I am a recent past chairman of that hospital, before it became part of the new Academic Health Science Centre of Imperial College. Of course, that is close to the heart of the noble Lord, Lord Darzi, as well.

One great thing about this House is that we have the opportunity to hear personal experiences. I have been enormously moved by the contributions of the noble Baroness, Lady Campbell, who it is so good to see here, and the noble Baroness, Lady Masham. I appreciated that there was great concern over the care of Lady Darcy de Knayth, and we are all dreadfully sorry that she is not with us still and that she had such a traumatic time towards the end. Of course, none of us can be thankful in any way for the sort of care that she received from the health service. By the sounds of things, I do not think that the noble Baroness, Lady Masham, herself has had a great experience.

From the remarks of the noble Baroness, Lady Campbell, she has obviously accessed one of the good units, which has provided the care that has ensured that we have the benefit of her thoughts and wisdom in this House. We are very grateful for that. We have had two cracking speeches from the noble Baronesses and of course one from the noble Lord, Lord Crisp, who has enormous experience of the health service. He is probably responsible for all those horrible targets and management-speak, which we all love so much, which had some influence on the NHS while he was part of it, and which he left as his legacy.

Turning to the main thrust of the matter, perhaps being involved with the hospital service in central London, I see this problem from a slightly different end of the telescope. The specialist hospitals and specialist units are almost invariably either in, or close to, acute services, and specialists across the spectrum are more often than not familiar with nearby hospitals or accustomed to attending the specialist units within their own. In any event, they are in a position to give advice on patients who are known to them. However, I accept that that may not be the situation in other parts of London, outer London or in the rest of the country. Even if a specialist unit or hospital is isolated, it should have access one way or another to the additional specialties that may be required for any patient who comes to it for care. On the other side of the coin, acute trusts should be in a position to access easily the specialist services that are required for particular patients so that there is flexibility within the way that care is provided.

I have certainly read the document High Quality Care For All—would I have dared not to have done?—produced by the Minister and it seems clear that the general thrust of the Government's future ideal for the health service is to establish more specialist centres for major trauma, heart attack and stroke. But those will, of necessity, be for acute care, and it will be for the Minister in replying to tell us whether those with chronic or long-term disease treated in them will have after-care access to the specialists who treated them in the acute phase. That is very much along the lines of the London Lupus Centre and the centres that have already been described as providing the ongoing care for patients who come to them.

However, those who already have long-term conditions and are under the care of specialists, as noble Lords have said, often develop other critical illnesses. If they do become ill with a complication of their underlying disease, or one that is unrelated, what access do they have to the physicians who have been looking after them or to their records to enable them to be properly assessed on both their acute and long-term conditions, as well as to the facilities that can support them?

The new, still incomplete NHS computer systems, which were partly to ensure ready access to records, are even now not able to achieve that. There is another question of when there will be a seamless transition to paperless records that can be accessed by any clinician on any patient wherever they may present. Perhaps the Minister can tell us whether we are likely to see that completed this century.

There is also the question of whether GPs are able to get a rapid update of the patient’s most recent condition prior to the crisis described by the noble Baroness, Lady Finlay, so that accurate diagnosis and treatment can be swiftly undertaken on the basis of the history as well as the immediate crisis. Clearly, if the information had been there, it would have been vitally important in Davina’s case. The commissioning that GPs undertake gives confidence to any acute or specialist unit that the patient is supported by them.

The noble Baroness has really made a plea for there to be flexibility in the system. That was also contained in the other speeches. Such flexibility enables specialists who know the patient to be called in to give advice and bring knowledge of the history of the patient to those who have had to assume care for them under different circumstances. Clearly, that is a sensible proposal that would work as long as the unit to which the patient has been admitted is close to the consultant or GP’s base. There is already concern about the practicality in terms of time rather than commitment of hospital consultants attending too many specialist clinics in the community. The implications of travelling some distance to provide advice on a patient’s care would have to be factored into a normal routine. It was helpful to hear from the noble Lord, Lord Crisp, that there are units where telephone consultations are normal.

I suspect that we would all agree that the NHS should provide optimal care to all its patients. Sixty years on, that is a modest ambition. The Minister's proposals for the future incorporate an ideal of high-quality care, a point made by the noble Lord, Lord Crisp. It has always struck me as odd that one of the main indicators for quality is mortality rates. Most patients expect to survive an encounter with the health service, but they also want it to provide them with care that is sensitive, compassionate, expert and, as far as possible, successful. Perhaps within that could be encompassed the kind of personal attention for which the Minister and other noble Lords here today are looking. Perhaps the quality marker suggested by the noble Lord, Lord Crisp, is one that the Minister might like to consider.

My Lords, I thank the noble Baroness, Lady Finlay, for calling this debate today. The issue that she raises is of significant importance to all who are treated and work in our specialist units. I will first declare an interest. Besides being a Minister, as most noble Lords will be aware, I happen to work as a surgeon at Imperial College Healthcare NHS Trust, where the noble Baroness did her training, and where the noble Baroness, Lady Hanham, happened to be chairman.

However, I should declare another interest. The noble Baroness, Lady Barker, spoke about what you could learn from portering. I know that she is right because eight years ago I had the opportunity to become a porter. You pick up many things if you see care delivered through the eyes of the porter, but I suspect that we are all here today to see how care is delivered through the eyes of the patient. My other interest to declare is that for the past two years I have been working in a specialist hospital, the Royal Marsden Hospital NHS Foundation Trust, on a two-day basis. Most would agree that that is a world-class cancer centre and one of many specialist hospitals within the United Kingdom. I am sure that I speak for all in the House when I pay tribute to our specialist hospitals and their dedicated staff who provide world-class care to many patients each year.

As I know from my own clinical practice, our specialist units can function as effectively as they do only because of the services and support provided by our acute general hospitals. In partnership, they ensure that patients receive the right treatments in the right settings at the right time. We should aspire consistently to deliver high-quality integrated care that transcends organisational and administrative boundaries. That is what matters to patients and that is why I welcome the noble Baroness’s inquiry and some of the issues that were reinforced by the noble Baroness, Lady Hanham, as the best way for integration of services to occur.

Any patient under the care of a specialist unit may experience a clinical deterioration, which may or may not be associated with their underlying condition. Let me describe a pathway of care for such patients. First, it is reassuring to know that in many cases patients can directly access the specialist team looking after them. Many specialist centres already have mechanisms that enable patients to do that, including 24-hour telephone lines, named specialist nurses and the opportunity simply to attend the ward themselves at any time. However, those patients will, on occasions, rightly attend their local general hospital to seek care. I am aware of fears that in such an event, a general unit may not have sufficient knowledge of the patient’s underlying specialist condition to provide them with the care that they require, but as with many issues in the health service, it is sound clinical judgment, and high standards of inter-professional communication and collaboration that are the key to high-quality care.

The noble Baroness alluded to the GMC guidance on good medical practice, which makes it clear that decisions on the most appropriate place of treatment for patients with complex needs are matters of professional clinical judgment. Clinical teams at a local level should therefore decide, following a detailed assessment of the patient’s condition and initiation of basic treatment, where these patients are best treated.

In some instances, patients will have developed a direct complication of their specialist condition, such as the blockage of a shunt in a neurosurgical patient. In this instance the most appropriate course of action is a transfer to a specialist unit, and many units have protocols to ensure that this happens in a safe, effective and timely manner. On other occasions, patients may present to the general hospital with a problem that is unrelated to the specialist condition. In this instance, transfer to a specialist centre is not only inappropriate but may be harmful to a patient whose clinical needs have changed. In this scenario, the patient will remain at the acute general hospital and the clinicians caring for them may notify the specialist unit of this complication to ensure good continuity of care.

If a patient is admitted to an acute general hospital with profound physical or mental needs as a result of their specialist condition, then we would expect trusts to put in place special arrangements to care for them. These may include increasing the amount of nursing expertise available to that patient, or ensuring that the correct equipment is present and functional within the trust.

As your Lordships can see, some patients have clinical requirements that may straddle the services provided by the general acute hospital and the specialist sectors. We recognise that patients want organisations to work together seamlessly across the whole of the NHS, and that organisational boundaries should never be an excuse for poor quality care. We can and will do more to ensure integration of care, as I described in the final report of the next stage review, High Quality Care for All. It sought to address many of the issues that this topic raises, specifically the delivery of high quality care and how we can ensure that services are integrated, personal and convenient.

We will measure the quality of care provided more than ever before, focusing on the quality of care from the patient’s perspective. We will enable commissioners of both local and specialist services to work together to ensure that the necessary networks of care are available to these patients. These measures, combined with the right to choice for which we shall legislate, will continue to raise the standards of care that we provide, regardless of clinical setting, to truly world-class levels.

The noble Baroness, Lady Masham, raised the circumstances of the late Lady Darcy de Knayth. It would be inappropriate for me as a clinician to comment on that. Suffice it to say that I extend my personal sympathy to her family. She was a much respected Member of this House whose input to debates such as this one will be sadly missed.

I have a few minutes in which to address some of our more detailed discussions. The noble Baroness, Lady Finlay, mentioned the constitution and eloquently highlighted some of the values and pledges that it contains. It is a consultation document. I urge noble Lords to participate in this consultation and to strengthen this document before it comes to the House early next year, as I understand it, as a Bill.

In chapter 4 of the next stage review, High Quality Care for All, I described in detail the quality framework that we have put together. First we defined what quality means, and within that definition of guidelines and standards we have certainly highlighted the needs of more specialist providers within the healthcare system. We have also described measures. I strongly believe that the measures which we are suggesting the professional teams should put together should measure not only outcomes, as the noble Baroness, Lady Hanham, mentioned, but the patient experience. Over the next decade we will be moving into an era in the NHS when there should be a higher regard for the patient experience than there was in the past.

We have gone even further, as those measures will be transparent and published. Patients in the future will be able to exercise choice—an informed choice rather than the choice that exists at present. Not only that, we are rewarding for quality. We suggest that from April 2009 every NHS provider will publish and be rewarded for reporting these quality measures. A year later, they will be rewarded for quality outcomes.

The moving speech of the noble Baroness, Lady Campbell, highlighted the importance of innovation and brought to our attention the fact that specialist hospitals have historically been the ones to pool innovation. This creative leadership at a local level has been highlighted at most specialist hospitals across the country. However, innovation should be the business of everyone who works in and delivers the NHS. Accordingly, in the NHS next stage review we will be mandating that strategic health authorities should make innovation a part of everyone’s business, while at the same time making available £150 million of funding for creative clinicians who wish to introduce innovations into their clinical practice. I could not agree more that quality, as I have said before, is a moving target. We should be constantly exploiting the technological innovations that we see daily and be much more proactive in introducing innovation into our clinical practice.

The noble Lord, Lord Crisp, raised points about integrating care and asked for my views on tailoring care more to the needs of the patient. The process of the next stage review probably taught us one of the most important lessons that we have learnt over the past 12 months—that change and innovation can happen only at the local level. For the first time, we engaged nearly 2,000 clinicians across the country at a local level. Through clinical leadership and the use of the evidence base, we challenged clinical working groups based on pathways of care, as eloquently raised by the noble Baroness, Lady Barker. We should stop talking about quantity and look at models of care through the patient’s eyes, starting from birth and finishing with the end-of-life pathway.

There has been the process of bringing different groups from different organisational models of delivery—primary care, secondary care, tertiary care, healthcare, social care—putting them around a table and challenging them on the best models of care, based on evidence, through which we provide high-quality integrated care, the fruits of which we have seen through the 10 regional reports. The challenge to us now is how we engage those clinicians who have charted the paths of the patient pathways into being more proactively involved in commissioning the pathways that they have suggested.

At the same time, we have announced in the primary and community strategy the pilots of so-called integrated care organisations, through which we can combine, or at least have the right incentives for, more horizontal and vertical integration, which I have no doubt will have a role to play in the future.

The noble Baroness, Lady Masham, talked about bed availability in specialist trusts. The latest figures that I have are for 2006-07, when the average bed occupancy for the NHS as a whole was about 84.5 per cent. Out of the 20 specialist hospital trusts, rather than units, for which I have the figures, in England, 16 had an average bed occupancy rate lower than that. It ranges from the lowest, the Royal Orthopaedic Hospital NHS Foundation Trust, which had a bed occupancy rate of 64.9 per cent, to the highest, the Queen Victoria Hospital NHS Foundation Trust, which had an occupancy rate of 95.3 per cent. On average, specialist hospital bed occupancy rates are much better than the national average. I do not believe that it is a capacity issue, but a co-ordination issue, as was highlighted earlier.

My Lords, I forgot to mention the importance of children and specialist units. I hear that Great Ormond Street has a waiting list, and it is a specialist hospital.

My Lords, I am grateful, and I agree. Great Ormond Street is one of the jewels in the crown when it comes to the provision of healthcare to children in hospital. We had the opportunity this morning to talk to the chief executive, Jane Collins, who is also a doctor, about the protocols in relation to the transfer of patients. Some noble Lords will be aware that 50 per cent of patients treated in Great Ormond Street Hospital come from outside London. It has some very detailed design of pathways and advice for patients once they leave hospital on how to contact Great Ormond Street. It is the most streamlined, patient-friendly and patient-centred service. We can learn more from it and disseminate that across the country.

The noble Baroness, Lady Barker, raised a few points, including portering, which I have addressed. I could not agree more about the use of technology as an enabler in taking away some of the boundaries that exist between organisations and institutions. For some reason, it seems that we have successfully implemented that in the neurosurgical discipline, where head injuries are transferred between organisations based on CT scans. We are seeing more examples of assistive technologies in the community, in managing patients with heart failure, among others, and caring for patients in their home environment.

I also highlight the importance of the ambulance service and how we can equip them with the right technologies. They have managed the tremendous success story in London, in transferring nearly 70 per cent of patients with myocardial infarct to the right place at the right time, into centres providing 24/7 acute angioplasty services. To do that, you need not only technology, but the right protocols, as the noble Baroness highlighted.

On the points raised by the noble Baroness, Lady Hanham, yes, the 10 regional reports highlight that each region has taken the evidence base and has set very challenging and ambitious plans in setting up some specialist services, such as trauma centres and stroke centres. I have no doubt that local ownership of the visions, with the enabling report that we have given, and transparency based on quality, will have a significant impact in making that happen.

I thank noble Lords for an excellent—

My Lords, I asked whether the units were acute care only or whether they would provide long-term care. Perhaps the Minister will address that.

My Lords, obviously trauma and stroke services are acute units. However, all 10 regional reports have some ambitious plans for patients with long-term conditions, which might be chronic illnesses; we all know that we have 17 million patients in England alone with long-term conditions. I came up with proposals for care plans signed by a clinician and patient in partnership and for integrated care organisations at primary and community level, such as community hospitals, where there is horizontal and vertical integration, so I could not agree more that we must have provision in primary and community services to meet some of the challenges facing us over the next 10 years. We will see more patients with long-term conditions, because the NHS has done the right job in managing patients with acute illnesses and converting those into long-term conditions. We need to capitalise on our successes in the past and build the infrastructure for the future to manage patients with long-term conditions.

Our specialist hospitals and units provide some of the most pioneering work in the world, as I said, and are rightly treasured by the public. However, they cannot provide all the care for all the patients required at all times; nor would it be appropriate for them to do so. We all agree that, regardless of the clinical setting, quality must be at the heart of the NHS and it should be everyone’s business. High-quality care for all is our objective, and we will be unrelenting in our drive to achieve it.

House adjourned at 8.45 pm.