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Volume 711: debated on Thursday 25 June 2009


Moved By

To call attention to the role of the National Health Service in learning from and promoting medical and scientific research, clinical teaching, health care delivery and social enterprise and cohesion; and to move for Papers.

My Lords, the United Kingdom has a proud record of achievement in medical research. It has received more Nobel prizes for physiology and medicine than any other country of comparable size, and it stands high in the world in the citation indices of peer-reviewed publications in medical and scientific journals. In this debate I shall concentrate on medical research and teaching and upon the vital contribution of the NHS, and I shall leave my noble friend Lord Mawson to discuss how the NHS contributes to social enterprise and cohesion.

In the 64 years since I became a doctor, advances in medical and scientific knowledge have been astonishing, and my theme today is to convince your Lordships that today’s discovery in basic medical science results in tomorrow’s practical development in patient care. This is translational research, meaning that basic scientific discoveries are translated into new methods of management of disease and its prevention. For anyone practising medicine before the NHS, as I did, the vast range of new and effective drugs has been phenomenal. Serious diseases which I saw as a young doctor, like diphtheria, poliomyelitis and scarlet fever, are rarely, if ever, seen, due to effective vaccination, while rubella, which may damage the foetus in a pregnant woman, and mumps are now controlled. Measles, too, should have virtually disappeared in the UK, were it not for the misguided campaign, based on flawed research, that caused the MMR vaccine scare.

With new antibiotics emerging, many bacterial infections have been defeated, but antibiotic resistance has caused the emergence of strains like MRSA and drug-resistant tuberculosis, while AIDS, still a major challenge, is now more effectively controlled by appropriate medication. Methods used when I was a young neurologist to identify the cause of strokes and to locate brain tumours, for example, often involved great discomfort and potential risks, but new methods of imaging, such as CT and ultrasound scanning, magnetic resonance imaging and its functional variant, have given us information about abnormalities in the body’s internal organs undreamed of a few decades ago.

Admittedly, there are still some incurable diseases, not least in neurology, even though developments in molecular biology, including gene identification and the discovery of the missing or abnormal proteins resulting from such gene defects, have raised hopes of new treatments for many such conditions, perhaps by gene therapy or other variants. The prospect of the repair of damaged tissues, so-called regenerative medicine, sometimes using adult stem cells but more often using the highly effective pluripotential embryonic stem cells, which can readily be converted into nerve cells, liver cells, kidney cells, heart cells and indeed many cell types, brings within sight the prospect, if not of immediate cure, certainly of amelioration.

As I always told my students, though, while there are still many incurable diseases, none is untreatable. All can have their effects modified by pharmacological, biological, physical or psychological means. I quote as an example the improved care of patients with the most severe form of muscular dystrophy, the Duchenne type, affecting young boys, who have progressive difficulty in walking and are confined to a wheelchair from about the age of 10. When I first began research in the 1950s, many such boys died in their mid-teens from heart failure or respiratory infection, having become grossly deformed through neglect of supportive measures. Now, in specialised centres such as London, Oxford and Newcastle, where ventilatory care is available, the average age at death of these boys is in the 30s, whereas in the south-west of England it is still in the late teens. As a result of a detailed survey by an All-Party Parliamentary Group and the Muscular Dystrophy Campaign, improvements in services for these patients and their families are pending, while the discovery of the responsible gene and of the missing product called dystrophin has led to major research initiatives in Hammersmith, Oxford and Newcastle, where clinical trials of exciting new techniques designed to circumvent the primary genetic effect are now in progress.

I must mention briefly the issue of stroke. This country has been lagging in its introduction and development of stroke units and in introducing new and improved methods of treatment. We know now that if one can recognise stroke and one regards it as an emergency—the public, the paramedics and the medical profession need to be much better informed about this—and if a patient is admitted within the three-hour deadline and can have an immediate scan to demonstrate whether the stroke is due to an infarct, as the result of the blockage of a vessel or a haemorrhage, then, if it is an infarct, clot-busting drugs and thrombolysis can improve the condition greatly. At the moment only 1.5 per cent of patients with ischaemic stroke in the UK are receiving thrombolysis. This is unacceptable, and measures must be taken to improve that position.

Many years ago, as a member of your Lordships’ Select Committee on Science and Technology, I chaired an inquiry into research in the NHS. Our report was endorsed by the then Conservative Government, who accepted that while much research and many treatment trials were being conducted in the NHS, there was no dedicated line of funding for health service research. Concerns then about the freezing of clinical academic posts in universities, appointments that involved not only teaching and research but also patient care, led to a major decline in recruitment. That inquiry led first to the Culyer report on NHS research, the Richards report on clinical academic medicine and, several years later, the outstanding Cooksey report on NHS research. Dame Sally Davies now presides over a National Institute for Health Research, supporting much research in the NHS.

The Conservative Government responded to our report by agreeing that 1.5 per cent of the NHS budget should ultimately be devoted to R&D, but the figure has never yet exceeded 0.9 per cent. While that is substantial, in view of increased NHS funding, what plans do the Government have to increase this figure to somewhere nearer the agreed target? Might additional academic health science research centres be established in places that narrowly missed out in the first tranche? As the recession bites, may we also hope—recent government statements are encouraging—that increased government spending on science, especially in the annual grants to the Medical Research Council and the BBSRC, will be maintained?

We must also acknowledge the massive support of research funding provided by the Association of Medical Research Charities, of which the Wellcome Trust is pre-eminent, although the disease-oriented charities have also made crucial contributions. In my view, it was a sad day when, some 20 years ago, the Advisory Board for the Research Councils removed infrastructure funding from the University Grants Committee, funds specifically allocated under the dual-support system to provide well-found university and hospital departments and laboratories, and passed that money to the research councils, fearing that the new universities, the former polytechnics, might seek such support, diluting resources available for the old-established universities. As a result, confusion arose about overheads to be paid by research charities. Under the UGC, overheads were not paid but now universities are acquiring full economic costing.

The Charity Research Support Fund, introduced by government and providing infrastructure funding for charity-funded research, is, I fear, inadequate, and I would welcome the Minister's comments. A recent survey by a notable charity found that only 5 per cent of 245 researchers funded by charities considered that fund adequate. One-third of those researchers found that universities were becoming increasingly reluctant to support applications for charities for research grants for that reason.

The NHS does, of course, play a vital role in the undergraduate and postgraduate education of doctors, nurses and other healthcare professionals. I was disappointed that education was not highlighted in the NHS Constitution. I shall be interested to hear from the Minister how the proposed health innovation and education clusters will nurture such education. The doctors and nurses of tomorrow are dependent on the facilities of the NHS for their undergraduate and postgraduate training. Do the Government accept that we must maintain the opt-out from the European working time directive for young trainee doctors? The restriction on working hours will have an adverse effect on training, and surgeons in particular are deeply concerned that, under the restricted hours now proposed, the training of surgeons will suffer.

Has the MTAS scheme proved a disincentive for young doctors wishing to take time out from training to undertake research? When I was head of a department, many young men and women came to the department in the course of training—as registrars and senior registrars—before moving on to apply for consultant posts, but a very large number of them took a year out from their formal NHS training to undertake a programme of research. I am informed by many heads of departments that, because of the MTAS scheme, that is becoming increasingly difficult for many young doctors to do. In my view it is crucial to recognise that a period of time spent in research nurtures the development of young doctors who benefit from that, and in the end it improves their ability to undertake practice and clinical care.

Happily, the NHS continues to fund many clinical academic posts in our universities, recognising the crucial role that such individuals play not only in teaching and research but also in patient care. Initiatives of the Academy of Medical Sciences and the Wellcome Trust in supporting clinical academia have been admirable, so that academic medicine is now in better heart. However, there are storms on the horizon as some health service trusts and even foundation trusts have questioned the need for such posts to be funded by the NHS. Does the Minister agree that the vitality of clinical academic medicine is essential if high quality research, teaching and patient care are to be maintained?

Finally, the NHS offers an ideal environment for clinical trials of new forms of treatment, trials often expertly assessed by the National Institute for Health and Clinical Excellence. Has the European Union directive on clinical trials had any adverse effect? Are the Government satisfied that seeking ethical approval of research protocols, especially for multicentre and multinational trials, where unacceptable delays have often occurred in the past, is now satisfactory? Can we be confident that research ethics committees contain a majority of scientifically literate individuals able fully to appreciate and to consider the scientific content of such research programmes?

For more than 40 years I was stimulated and inspired by my responsibilities in clinical academic medicine, involving teaching, patient care and research. I firmly believe that those three branches of academic activity are interdependent and mutually beneficial, and that the NHS is probably the finest clinical laboratory that exists anywhere in the world for the pursuit of clinical and translational research with the objective of improving disease prevention, treatment and cure. May it continue to flourish. I beg to move.

My Lords, I congratulate the noble Lord, Lord Walton of Detchant, on obtaining the debate today and on the typically informative and vigorous way in which he has introduced our discussion. I pay tribute to him for his distinguished medical and academic career in this area. As a non-medic, among a number of distinguished medics who are to address your Lordships this afternoon, I shall speak with some humility about the issue of quality. To set the scene, I shall talk about quantity. Ninety-three per cent of patients requiring admission to hospital are admitted within 18 weeks; not many years ago the waiting time was two years. In quantity terms there has been a real improvement.

When I was an MP, 30 years ago, I got to know someone in my constituency who had cataracts in both eyes. He was a working-class man who was quite poor and could not afford private treatment. He was virtually blind but he never received treatment in the health service before he died. Now there are 250,000 cataract operations a year and the average wait is 10 weeks. I often think of that man when I consider that statistic.

As regards hearing, I declare an interest in that one of my granddaughters was born profoundly deaf. Under the National Health Service, she had cochlear implants on both sides and, thank goodness, she is a very vigorous and energetic four year-old. Hearing is a very big problem for a lot of people: 400,000 people a year are referred to audiology departments. They are not the big glamour operations for many people but they are very important to people's lives. That is the quantity issue and I now turn to the issue of quality.

The noble Lord, Lord Darzi, led the NHS Next Stage Review which was published last year entitled High Quality Care for All. It said that we need to move from an NHS which is rightly focused on increasing the quantity of healthcare to one which focuses on improving the quality of care. If quality is to be at the heart of everything done in the NHS, it must be understood from the perspective of patients. That is quite a change in many parts of the NHS. Patients are concerned with both clinical outcomes and their experience of the service. If you go to a restaurant you tend to go back to one where perhaps the food is not always good but the overall treatment, including courtesy, is good.

Improving the quality of service has to involve everyone. It requires a true team effort, with everyone committed and everyone proud of the achievements. The noble Lord, Lord Darzi, was right to say that change is most likely to be achieved if it is led by clinicians. I agree with that. The emphasis should be on teamwork and inclusiveness. In many hospitals, still too large a proportion of staff feel undervalued and in some—I do not say all—major hospitals senior medical staff are still viewed with awe or fear rather than as lead partners in achieving high quality outcomes and patient experience.

The NHS is a large and daunting structure for patients, and I wonder whether we do enough to integrate the patient’s needs and experience through primary, secondary and tertiary care. People often go through all those. Is enough done to take people through that on a continual basis, avoiding cancelled appointments, missing or out-of-date information, so that they have to go back again to see the consultant, and all the things that we know can go wrong?

A few years ago, I suffered from an underactive thyroid—I still do, of course—and I went to see many NHS consultants, until I found one who knew what it was, although it was not his specialisation. I had an appointment to see one chap and, as noble Lords would expect, I arrived for the 12 o’clock appointment at about three or four minutes to 12 o’clock and discovered eight people waiting. When I asked the secretary whether the specialist was on time, she said, “Yes, but you’re eighth in the queue”. Twelve o’clock did not mean 12 o’clock; it meant that that was when a group of people turned up. I had to cancel the appointment because I had a number of other things to do that were extremely important, more important than my health. I cancelled the appointment and felt very bad about that. In that little microcosm, that NHS cost itself resources and money, it did not do the patient experience any favours and left me feeling very frustrated. Nobody gained, and nobody got a grip on it.

Raising quality does not mean increasing costs or reducing productivity, far from it. In my view, raising quality is about addressing the whole process of delivering a health requirement and means finding ways to deliver more for less, provide more time to improve the patient experience, review outcomes and seek further improvements. My view, speaking with a business school background, is that the message that improving quality will cost more and reduce productivity so that we cannot afford to do it is far from the truth. We can have more for less if it is seen as a process, not in isolation. Times are going to be tough for the NHS in the next few years. There will be plenty of people saying that they cannot afford to have meetings to discuss these things because they have enough on as it is, but I believe that it can be achieved.

When I was in the United States not long ago, talking about the health industry and the role of medically qualified people, I discovered that in some of the states that I visited up to 50 per cent of chief executive officers are medially qualified. I came back to this country and asked for the figure and it is about 2 per cent. The difference is staggering. I ask the Minister to consider whether there is a serious career structure for medically qualified people who want to add value to the NHS on that basis. In my view, that is critical to improving quality and performance. Is the financial reward structure adequate? My guess is that it is woefully inadequate. My message is that quality matters and is not something that cannot be afforded when times are tough. Quality improvements are even more important when times are tough, and getting the right people leading teams and making a real team effort requires an improvement in the way in which medically qualified people are involved in the senior management running the health service.

My Lords, I greatly welcome this debate and listened to the speech of the noble Lord, Lord Walton, with pleasure and close attention. I am wholly a layman and I speak as a patient about one niche of concern. Eight years ago, I had a stroke. I was very lucky; there was no apparent physical damage, but my reading, writing, speaking and comprehension were severely affected, and I had two and a half years of speech therapy. I raised this matter in the House in a debate three years ago, and I have since had two similar opportunities to discuss stroke.

Initially, I was critical of the NHS, and particularly Health Ministers, for neglecting, over many years, the causes, consequences and treatment of stroke, which had an unacceptably low profile among major diseases. These shortcomings were set out in a devastating report by the Comptroller and Auditor General in 2005. More recently, there has been substantial progress, as the noble Lord, Lord Walton, said. The Stroke Association called its recent document Getting Better, which is just about right. I should add that I am a member of the All-Party Parliamentary Group on Stroke, which is ably chaired by Andrew Lansley MP, the Conservative health shadow who has recently been having a rather tough time.

Today, I am looking at stroke again, on this occasion in the context of the new National Sentinel Stroke Audit published by the Royal College of Physicians in April, and at the role of stroke research. I have already warned the Minister of my particular interest, and I hope she will be able to respond. In sum, I am disturbed that the new sentinel audit report shows that there remains a serious gap between what is actually happening and what should happen. There have been significant improvements. Twenty-nine per cent of patients are now admitted to a stroke unit on the same day and 57 per cent are admitted either the same day or on the following day. That is a major step forward since 2006. There have also been marked improvements in the speed of assessment by therapists after admission. All this is good.

However, the headline of the sentinel audit is that a quarter of stroke patients are still not given the best treatment. It refers to,

“unacceptable variations in the quality of care between hospitals with some parts of the country still failing to provide anything approaching an acceptable service”.

There is even a group of hospitals,

“that appear to have deteriorated - a few by very significant amounts”.

I regard that as alarming.

Professor Roger Boyle, national director for heart disease and stroke, the so-called tsar, has commented on the audit. He said:

“The national stroke strategy is a ten-year plan, and there are no simplistic quick-fixes ... But, by making stroke a number one priority for the NHS, providing extra funding and establishing the Stroke Improvement Programme and local stroke networks, we are now firmly aiming at the revolution in stroke services”.

I have great respect for Professor Boyle and admire his commitment. However, will the Minister confirm that the 10-year plan is on target, that the extra funding is in place and that it will remain undiminished with no delay or redesign, which is a familiar euphemism for setting something aside?

Within the national stroke strategy, there is yet another strategy, the stroke research network or SRN. The health department says that:

“The SRN provides a world-class health infrastructure to support clinical stroke research and remove barriers to its conduct”.

I should say that three years or so ago, I agreed to become a patient representative on the Thames Stroke Research Network and, later, played a very modest role in its launch in April 2007. I am concerned about the stroke networks and whether they have been established on time and are achieving their preliminary purpose. I should be grateful if the Minister would confirm that that is the case and that the department intends to make them a permanent feature within the continuing national stroke strategy

I have said that strokes have been the poor relation—if I may put it in an awkward way—of other diseases. This has been reflected in inadequate research funding. According to a Written Answer in the House of Commons, the aggregated expenditure on stroke research in 2006-07 was £9.87 million—a tiny sum. I find the Answer confusing, because it adds that comparable information in respect of the department’s centrally managed research programmes is not available. I ask the Minister why not, and, in particular, where can I find the costs of the Stroke Research Network?

I come briefly to the current outlook, taking into account the national financial and debt crisis and the prospects for public spending, especially on health and health research. In a long political life I have become familiar with such crises, to which I have been uncomfortably close. Ministers of the day have admitted the quantum of lower expenditure, but tried to hide the damage. They have concealed the consequences by discreetly scaling down plans, delaying capital investment and using expenditure figures in cash rather than real terms. They have talked about huge sums in unspecified efficiency savings, making everything stronger, leaner and fitter. However, I am afraid that much of what has been called painless has been cuts by stealth.

Until a few weeks ago, there was a remarkable silence about public expenditure cuts beyond 2011. The King’s Fund says that the NHS could face drastic cuts as the service moves from years of significant growth in its real terms funding to very low, zero or negative growth. Will the Minister say in plain terms whether the Government agree with the King’s Fund or whether, to the contrary, they intend to preserve fully and ring-fenced, as I have previously understood, the current level of spending on the NHS, as well as other government health spending, direct or indirect—for example, spending by the Medical Research Council? If the latter is the case, I am reasonably reassured about stroke research, such as it is. If not, I am deeply concerned.

My Lords, it is a privilege to share this debate with my noble friend Lord Walton. I begin my contribution to the debate on the future of the NHS by addressing my remarks to the opportunities presented by social enterprise for the future of health and, in particular, primary care.

In recent months, many of us have listened with growing concern to the unfolding story of Baby Peter in Haringey—one of the tragedies that point to the lack of joined-up working between health and social care services and to an insufficient focus on people. Despite years of talk about joined-up working and putting people first, this is still very patchy in practice. While we have moved some way down the road to co-locating services in primary care buildings and to recognising the role of social entrepreneurs in health, we still have a way to go in making greater use of community and integrated approaches to health and in using the talents and ingenuity of local people.

I was interested to hear my noble friend Lord Laming, in a Radio 4 interview, describing how difficult it was for Ministers to get the words about joining up health and social care off the pages of glossy reports and into reality on the streets of our towns and cities before yet another crisis erupts on to our television screens. I suggest that putting people before structures is the only practical way of joining up services and implementing a truly integrated approach to primary healthcare in this country. We need to use the innovative skills of social entrepreneurs and organisations that have a proven track record and to back such people by giving them the resources and freedoms that they need to transform the health and well-being of the communities that they serve.

Many of these people are doctors—I have worked with some of them. Many others are individuals working in third sector organisations and leading teams of dedicated people committed to improving health and social care services in their local communities. These people seldom appear on the NHS radar and, even when they do, are rarely valued for the contribution that they make. The tragedy is that despite the years of commitment to new commissioning structures—third sector compacts, social enterprise initiatives and the like—there is still little widespread procurement of local holistic services from social enterprises or the third sector. The true meaning of “third sector procurement” seems to be in the name itself. Successful third sector organisations and social enterprises often feel that they are the third choice—that the bits that the public sector might not want to deliver get passed down the line. Second in line is the private commercial sector and, finally, at the end of the queue, we have the third sector patiently waiting its turn for the crumbs from the table.

The poor souls in the third sector are no third-rate choice. The third sector is like any other sector—better in some places than others. Our approach to procuring health and social care services is ignoring some of the most talented and innovative individuals and organisations—people who have been working tirelessly in their communities for far longer than the perennially reconstituted PCTs and health authorities.

This is my experience over 25 years in Bromley-by-Bow in east London. Over the years, rhetoric around the holistic integrated model has never been matched by an integrated commissioning structure that delivers a Bromley-by-Bow-style approach to public service delivery, community regeneration and social enterprise.

I am afraid that I see little room for optimism in the latest polyclinic initiatives. The noble Lord, Lord Darzi, and his team have produced a programme for primary care that will produce wonderful new buildings and a new level of integration that has never been seen before. However, I have a profound problem with the scheme. At its heart it is still a biomedical model of healthcare that focuses on delivering clinical interventions for patients. Important as this is, it is only one dimension of a multidimensional problem. We are building not polyclinics but monoclinics.

I am sure that the Department of Health recognises the multicausal nature of chronic ill health in our communities. However, after all these years of rhetoric, we still seem unable in this country to create commissioning structures that cut across the departmental silos of government and focus on the customer. Why should that be? In my view, there is a problem at the core of our understanding of integration. Many in the public sector still think that this is about only traditional bits of the public services working more closely together.

We need holistic approaches to public service delivery that use social enterprises to deliver better services and better value for money across a range of measures. Where better to start this approach than in primary care? These solutions are particularly relevant today when the financing of the medical intervention model has been put under severe strain as a result of the financial crisis. However, I fear that despite the rhetoric the Government—and perhaps a future Government—still do not understand how practically to use entrepreneurs in the delivery of health services. I know that it works because in the past few years I have had the privilege of seeing and working with such entrepreneurial health organisations across the country. These organisations put people first because they understand and are part of their communities. They bring together health and social programmes. They are trusted, not because they engage in elaborate consultations but because they have a track record of delivering services that local people need.

There is of course no shortage of action by the Government. A multiplicity of programmes for the provision of integrated health services by the public, private and social enterprise sectors has been initiated. My concern as I travel across the country is that these initiatives, while well intentioned, by and large do not rely on the ingenuity and talent of entrepreneurs and local people but continue to use the old bureaucratic and paper-based mechanisms. Bureaucracies like talking to bureaucracies and doing many of the same old things that they have always done. We are putting old men in new clothes. The rhetoric has changed but in practice it is still difficult for social enterprises to win APMS contracts to run GP surgeries, despite that being possibly the best way to spread entrepreneurial talent in the health sector, as my friend Dr Michael Dixon of the NHS Alliance has suggested.

As I have listened to debates in your Lordships’ House in recent months, Ministers, including the noble Lord, Lord Mandelson, have highlighted in public conferences the virtues of social enterprise. Yet in the health sector basic conversations are still not taking place. I have spent the past five months since the publication of our report on social enterprise and health—here I must declare an interest—attempting to bring Ministers to the same table as colleagues from NHS LIFT and the Big Lottery Fund in order to bring new joined-up investments to support an integrated approach to health.

What the Government have done to date is commendable, but the NHS now needs to change its paradigm from the expensive clinical model to one based on networks and more modest-scale and sustainable initiatives that can be private, public or social enterprise—it does not matter. What matters is that entrepreneurial leadership and organisational culture put people, not systems, first.

If this Government—or a future Government—are serious about the future of the NHS and about social enterprise and community cohesion, I humbly suggest that a first step might be to do the following. First, they should ensure that their programmes are led by individuals with a strong track record of enterprise and appropriate risk-taking, as well as delivering innovation in mid-sized organisations. These should be people who understand the challenges of growth businesses; this is a job not for academic civil servants but for social entrepreneurs. Secondly, the Government must stop being fixated on new health initiatives and focus on making sure that the basic framework is in place to support communities in the delivery of their health services. Thirdly, they should move from a generalised support for social entrepreneurs to an informed support, which understands in detail how an entrepreneurial approach helps to deliver efficient services in the health sector. As always, the devil is in the practical details. Fourthly, they must start to assess health interventions not through reports and targets but through a focus on the health of patients and their care. Too often you get what you inspect and not what you expect. Fifthly, we need to ensure that all procurement opportunities by the Government are open to social enterprises and that procurement is not biased against small organisations. This applies very clearly to the procurement for GP surgeries under the APMS arrangement. Finally, we need to ensure that different interventions by the Government and actors talk to each other. This is not happening at a very basic level across the country. This is the road to enterprising healthcare and social cohesion.

My Lords, I, too, congratulate the noble Lord, Lord Walton, on introducing this important debate in such a characteristically lucid way. No one seems to deny that medical research is vital for our future health and healthcare, least of all me with my interest as scientific adviser to the Association of Medical Research Charities and as a past clinical researcher. If anyone needed convincing, they had only to listen to the debate introduced earlier today by the noble Baroness, Lady Murphy, to realise the enormous personal and economic costs of dementia and Alzheimer’s disease and the potential benefits that could accrue from successful research in that area. I make no excuse for focusing heavily on research, to which this Government have shown a clear commitment. They have put more into general and medical research in particular than ever before. The Prime Minister has reiterated his strong support in giving research high priority, as have my noble friends Lord Darzi and Lord Drayson on our Front Bench.

I focus my remarks on two topics that are seen to be major inhibitors of research in the UK. First, there are the difficulties posed by the multitude of regulatory bodies that have to be satisfied before research can go ahead. Secondly, there are the hurdles that have to be jumped before research can be done not on the patients themselves but on information and data about them.

I return to the subject of regulation. Despite valiant attempts at bureaucracy-busting by many, including my noble friend Lord Warner when he was the Minister, researchers are still faced with a rising tide of form-filling required by innumerable bodies that seem to take for ever to respond. A recently appointed lecturer, funded by the new and welcome investment from government and charities, will often spend the whole of his or her first 12 months waiting for approval to do the research that they were appointed to do. What a terrible waste of time and money. The pharmaceutical industry is also looking to other countries in which to do its research because of the long delay before it can get approval here.

No one denies the need for careful and thorough regulation of research on patients—certainly not the researchers themselves. They gain funding through a rigorous peer review, against considerable competition. They have to gain the approval of the Research Ethics Committee, which is entirely appropriate and necessary. Yet sometimes they have to go through several ethics committees if patients come from different trust areas. We can run into problems where different ethics committees come to different conclusions on whether they should approve the same research. There is a bit of a postcode lottery.

Yet it is the multitude of other bodies that need satisfying where the main difficulties arise. We have the local trust R&D committee, the Medicines and Healthcare Products Regulatory Agency, the Human Tissue Authority—where tissues are to be used—and several other bodies depending on what type of research is proposed. All require their own forms to be filled in, which are often long—up to 80 pages for some—and they all have different timeframes and dates at which they will consider submissions.

Paul Stewart, a distinguished researcher in Birmingham, writes that the current bureaucracy placed on investigators,

“is poorly coordinated, lacks consistency at all levels, and at times is completely illogical”.

This is no way for the UK to keep up with the competition. Our patients, the ultimate beneficiaries, deserve better. I am afraid that I have asked this before, but will the Minister have another go at bureaucracy-busting and rationalise the number of different bodies involved in this confusing array of regulators?

Secondly, there is the need to do research not directly on patients themselves but on information or data that already exist about them in the NHS. The NHS is an enormously valuable repository of information about patients, their diagnoses, treatments, cure rates, causes of death and so on. It is the envy of the world in the completeness of its information about the whole population. It provides an extremely fertile resource for research. The problem lies in trying to balance the need to carry out that research with preserving patients’ confidentiality and trust. Questions of data protection and definitions of what constitutes informed consent or anonymisation—a horrible word—remain difficult to resolve.

There is usually little problem where patients can give their consent and understand the nature of the research, the consent of an ethics committee has been obtained and there is the knowledge that those conducting the research have a professional responsibility to maintain confidentiality. Yet there are many situations where research is needed on stored data where patients are no longer accessible. They may have moved, died or be otherwise untraceable—a seeming Catch-22 situation. Similarly, where a researcher is gathering data from large populations with whom he or she has no direct contact, he has to rely on others to seek their consent even to be approached to obtain consent.

There are ways through this difficulty. One that I hope can be actively pursued is that proposed in the Walport-Thomas data-sharing review of last year, which involves the depositing of patients’ data in a databank under the control of a regulated controller. He or she may then agree access to elements of the data to bona fide researchers who have an ethically approved and rigorously reviewed research project. This would have to be entirely dependent on the patients’ approval to place their data in such a bank. For that to happen, the NHS needs to inform patients so that they are aware not only of the uses to which information about them may be put and are comfortable with that but also of the value of the research to them and to future generations. These are the bones of a system which could work and which I believe Dame Sally Davies, director of NIHR, and Harry Cayton, director of the National Information Governance Board, are striving to achieve. I am not sure how much of a push they need to achieve it.

Earlier this week I was at a meeting of the organisation DIPEx, a charity of which I am a trustee and which funds the website healthtalkonline. It is a wonderful organisation that takes interviews with real patients in which they describe their illnesses—breast cancer, rheumatoid arthritis and so on. It has gathered about 50 of those interviews online for patients to gain an inside picture of what it is like to have their illness from others suffering from the same thing. The website gets lots of hits every week. The interviews are enormously valuable, too, for medical students in training. I mention this organisation now because its latest offering is on clinical trials, which gives a picture from a range of patients of what it is like to be involved in clinical trials directly or indirectly using their data. I hope that, in the PR exercise that the NHS should engage in about the importance of research and the need to use patients’ data, the department will make use of this resource and information to help to get its message across.

My questions for my noble friend are, therefore, whether she will give us some encouragement that the regulatory burden on researchers will be eased by rationalising the number of bodies that have to be satisfied, whether she will ensure that the use of patient data for research will be put on a more rational footing and, finally, whether she will look at the DIPEx website, healthtalkonline, and see whether she can make more use of this marvellous resource.

My Lords, I, too, thank my noble friend Lord Walton for initiating this important debate. I shall follow on from the subjects mentioned by the noble Lord, Lord Mawson.

It is now a year since we celebrated both 60 years of the existence of the NHS and the publication of the report of the noble Lord, Lord Darzi, High Quality Care For All. The report provides an exciting challenge for the NHS to provide a world-class service. The areas to be addressed are set out within the report and many are on the way towards implementation, but in the short time available to me I should like to explore the challenging issues relating to integrating services in the community.

I shall focus on three paragraphs from section 5 of the report, entitled, Freedom to focus on quality. The first is paragraph 24, which begins:

“This transparency must not be limited to acute health services”.

The second is paragraph 30, which states:

“We will empower clinicians further to provide more integrated services for patients by piloting new integrated care organisations (ICOs) bringing together health and social care professionals from a range of organisations – community services, hospitals, local authorities and others, depending on local needs”.

The third, paragraph 31, headed, Fostering leadership for quality, begins:

“Greater freedom, enhanced accountability and empowering staff … making change actually happen takes leadership”.

The patient pathways have been welcomed, but many gaps remain on the patient journey, as both the noble Lords, Lord Woolmer and Lord Rodgers, mentioned. Paragraphs 24 to 25 indicate that the measurement of quality care is not limited to the acute sector alone. Therefore, during 2009, a quality framework to develop services will also be completed, with a standard but flexible contract to enable commissioners to hold community health services to account for quality health improvement. That will take account of local populations, including the most vulnerable or excluded people with complex needs. It will be managed by the strategic health authorities and include annual associated health outcomes, competencies and governance. PCTs will have started to implement the system in March 2009, and first results will be formally published in March 2010.

These are admirable targets, but we know that patient pathways are not entirely NHS managed. Immediate families, carers and other statutory or third-sector agencies need to be involved, as was clearly set out by my noble friend Lord Mawson. This requires empowering NHS staff and can best be described as “learning and doing”. There is a need to restore passion combined with experience to ensure that holistic, high-quality care is delivered against the important backcloth of theory, statistics and policies arrived at from evidence-based practice, but always taking account of the prevailing needs of the individual and immediate family or carers and local community environment. Will the Minister indicate the progress being made in implementing the integrated care organisations, illustrating that patient pathways are not limited in access and that integrated services are the overall aim?

That brings us to the requirement for leadership skills to ensure that these implementations can successfully take place. Leadership is central to ensuring the delivery of high-quality care. In the words of the report:

“Leadership has been a neglected element of the reforms of recent years”.

It is acknowledged that there are many routes to effective leadership, but what is required here is for people to hold meaningful conversations that transcend organisational boundaries. The core elements of any approach to leadership towards change in the NHS are, first, vision; identifying what improvements need to be made. Secondly, method; how will they make the change happen? Thirdly, expectations; what difference will the necessary behavioural change make to people?

I too listened to the radio report by my noble friend Lord Laming following the Baby P case and I summarise his words. It seems to be generally agreed that the current policies, legislation and practice guidance is fundamentally sound. The problem is the gap between the written word and the day-to-day activity at the front door of each of the key services. The challenge is to get the written word off the page and into the bloodstream of each of the services. Failure to do so has resulted in a marked reduction in the confidence and willingness of health visitors, paediatricians, GPs and accident and emergency departments, as well as the other front-line services, to become involved in the safeguarding of children. The gap between theory and practice is great; similarly the gap between the claims of senior managers and the experience of front-line staff is too great. Yet the vulnerable depend, not on brave words, but on practice skills. Now is the time to address both the competence and confidence of front-line staff and to ensure that the performance of senior managers is judged against the quality of services delivered. The focus must be on better outcomes for service users. That being so, there must now be a major review of the quality and content of training. I suspect that many trainers are more comfortable debating different theories rather than focusing on practice skills. Now is the time to ensure that in future courses should be assessed on their ability to promote the highest standards of good practice.

I can identify with this very erudite statement, having had, during my career, experience in teaching a course correlating theory and practice and as a manager leading the closure programme of two large mental handicap hospitals and five large mental hospitals, a programme that I am sure the noble Lord, Lord Warner, will identify with, as one of the directors of social services involved. Leadership skills were needed to cross the boundaries between the NHS and social services in an unprecedented way during that 10-year programme, which involved patients, families, communities, housing associations, and third-sector organisations. However, that was 20 years ago and there are still lessons to be learnt. Not all barriers have been eradicated and gaps do still exist in many places, but in others, high-quality services are in place or are being developed. I declare an interest in that I am one of the 20 commissioners appointed to the Prime Minister’s Commission on the Future of Nursing and Midwifery. Within the terms of reference, there is an opportunity to progress the work already in hand following the recommendations of the High Quality Care for All report, but also to explore and recommend innovative ways of closing the gaps in patient pathways and overcoming the boundaries that prevent the holistic, seamless care that we all know is necessary in order to deliver world-class quality care to the communities we serve. These communities differ according to their locations and range of populations, but the three key requirements I began with are fundamental—transparency not limited to the acute sector; empowerment of staff through appropriate education, training and support; and leadership of front-line services by accountable boards, able to cross boundaries and not confined in silos.

I hope that the commission will be able to make recommendations that allow for innovation and for the entrepreneurial skills so eloquently demonstrated as necessary by my noble friend Lord Mawson. These issues need to be addressed, so that patient pathways can be complete and holistic care of high quality received by patients and families.

My Lords, like other noble Lords, I thank my noble friend Lord Walton of Detchant for initiating this debate. I intend to follow up on one of his chosen themes of social cohesion and focus on that factor. In particular, I want to look at the role of the NHS in maintaining social cohesion in Northern Ireland during the Troubles.

At a time when it is commonplace to read in the media about former terrorists travelling the world and giving advice about conflict resolution to other countries, and to see them receiving much applause for so doing, it is an appropriate moment in this House—it is thanks to my noble friend Lord Walton that we have this chance—to talk about some of the real heroes of the Troubles. In Northern Ireland, more than 3,500 people out of a small population of 1.5 million were murdered through political violence. Tens of thousands more were mutilated and suffered the most horrible injuries. That placed an extraordinary burden on the NHS over a 30-year period, a burden it met in an absolutely remarkable way.

I declare not an interest but a bias in that I am a child of a Belfast medical family; both my parents worked as doctors in the NHS all their lives, apart from when they were in the forces during the Second World War. I think it is important to acknowledge the role that the health service played.

Let me begin by presenting a general picture: doctors experienced serious difficulties going about even daily work; regular bomb hoaxes led to massive traffic jams in which nurses and doctors would be stuck in frustrating positions, trying to reach their hospital or their place of work. That was almost the easiest part of the Troubles. Illegal checkpoints at certain points during an occasion such as the UWC strike in 1974 led to health officials negotiating with strikers to get permits so that doctors and nurses could be let through. It may have been a necessary and, indeed, a pragmatic adjustment, but it was undoubtedly felt by doctors and nurses to be humiliating.

Things became even nastier. Staff were murdered at the Royal Victoria Hospital site, which also witnessed a gunfight in the main corridor. Musgrave Park Hospital was bombed. Three hospitals in Belfast—the City, the Mater and the Royal Victoria—suffered the ultimate insult of having patients shot in their beds.

During the hunger strike movement of 1980-81, again the medical profession was thrust into the forefront of the crisis and emerged with its status and professionalism enhanced. Throughout the entire time of the hunger strikes, it acted under previously agreed protocols but at the price of stepping back from the requirement to save life. So it was not a moment without ambiguity.

From the standpoint of medicine, novel forms of injury arising from the Troubles presented themselves. Expertise in the treating of gunshot and bomb wounds emerged, and a new expertise was gained in running a hospital under the pressure of an influx of the severely wounded and dying. This was learnt the hard way—almost an anodyne phrase. One nurse interviewed about this recently said that when the casualties came in from the Abercorn bombing, she felt that she was actually at the gates of hell.

One doctor quoted in Candles in the Dark, the forthcoming Nuffield Trust study of the impact of the Troubles on the NHS, said something which summarises the ethos of the NHS during this period:

“I don’t remember very much about ethics training but I do remember a very strong informal ethos which was that we were doctors, we were Health Service and we would treat everyone with respect—regardless of who, why, where, their involvement, non-involvement and what part of the community they came from”.

This quotation expresses a profound truth and in its way is the best possible tribute to the work of the NHS during the Troubles. It is a tribute which should also embrace those pharmacists who kept open their dispensaries when riots were going on nearby and often under very difficult circumstances.

Having said that, I do not wish to end by giving a purely panglossian picture of the NHS and how it works in Northern Ireland. In his very fine book, Minority Verdict, published in 1995, Maurice Hayes, a distinguished Permanent Secretary at the Department of Health and Social Services in Northern Ireland, and a most eloquent defender of the core principles of the NHS, none the less admits that it was hard to defend, for example, a level of prescribing in Northern Ireland which was 25 per cent to 30 per cent above the UK average. It reminds us also of another unsung hero of the Troubles, the unknown British taxpayer. Dr Hayes adds in his fine book:

“A more basic question was whether the NHS was adequately funded and properly managed. The answer on both counts is, I think, no”.

Dr Hayes’ book was published 14 years ago. At that time, NHS expenditure was 5.6 per cent of GDP. Since then, expenditure has risen markedly, but there is still, in certain quarters, and for reasons already listed by the noble Lord, Lord Walton, and other speakers, disappointment with certain outcomes; certain key issues which have to be resolved. That is the core subject of our debate—whether we are talking about Northern Ireland or the United Kingdom as a whole.

My Lords, when I saw the title of this debate about the National Health Service and the words of the Motion, I am afraid that I did what many of us do—I picked out the bits that I like in order to get across the message that I want to send. So I will not be talking much about scientific research but will be discussing the possibility for the NHS to drive the agenda.

Will the NHS be an engine of lobbying within government to achieve certain objectives in other departments? The noble Baroness will not be terribly surprised that I am talking primarily about encouraging greater physical activity and exercise—an issue which has lately received a greater degree of push primarily because of the Olympics, which have upped awareness not only of sport generally but of healthier lifestyles. There have also been revelations about this becoming an increasingly obese society.

There are many things you can do, but much of what we hear about from the Department of Health and the NHS is about dealing with those who are already morbidly obese. What we do not hear as much about, and very little until very recently, is how we can stop people getting obese. One of the most important things we can do is to get the NHS to lobby to make sure that it is easier to take exercise.

Much can be said about food and overeating. Eating for many of us is at least partly a leisure activity—something that is pleasant. Very few of us eat purely for fuel. Eating is something we do when we are sitting down. It is something to do with our hands when we are watching television—probably the great driver of obesity is watching television and snacking. If we encourage people to take physical activity and exercise in other ways, they will probably not spend as much time sitting down, doing nothing and snacking, and they will be burning off calories.

Your body is designed to be used. It is designed to have a degree of physical activity to function properly. We also get obsessed with the idea of weight. I will not give the House another diatribe on how useless I think the body mass index is as a description of health. When Steve Redgrave won his last Olympic medal, he was not obese; he was merely very heavily overweight, according to the index. It does not refer to the fact that muscle per volume is incredibly heavy compared with fat. You can carry a lot of fat and it weighs less than a smaller amount of muscle. In fact, you can get much fitter and gain weight in many cases.

Will the NHS have some form of input into the rest of government, including local government, to make sure that it is easier to take exercise, so that exercise can be a fun activity? Will it use its huge political power to make sure that it does this job? You cannot cut the NHS, or say that you will cut it, without paying a price in the press. If it were, for example, to ask other parts of government, including local government, for the provision of parks that were pleasant to walk in and that children could play sports in, with properly maintained swings and playgrounds, that would do more to move the rest of government than would action by almost any other department. It could put pressure on the rest of government to ensure that we deliver something beneficial to health.

Physical activity was recently described to me as a wonder drug—it prevents the problems of being overweight and can act as a cure. However, not everyone wants to give up a huge chunk of their life to play sport—I did not for many years; that is the fact of the matter. If you do not have what is effectively an addiction to give up one day a week for eight months of the year to play a sport, and a number of other days for training, you will not get a buzz from it and you will not do it. But if it is light exercise and a pleasant activity, people will do it. We can encourage them to walk dogs and go out for a walk themselves. A journey by foot that you would have had to make anyway can be a pleasant way to exercise.

We could get away from the need for such measures by getting rid of half the technology in our lives, but we are not in a hurry to do that. How can we make sure that the NHS drives this on? It could save considerable sums by getting involved in some of the acute problems for which there is no easy preventive solution. How can this investment be used? What thinking is going on? How does the NHS see its involvement in pressuring the rest of government to achieve this? That is the question that we should be asking today. If we do not have an answer, it is probably because the NHS has been warned off. The Department of Health has warned it off. Unless the NHS is prepared to interfere and make itself thoroughly unpopular with one or two people by changing their plans, it will not happen. Achieving consensus is all very well, but occasionally you have to make one or two enemies to make one or two friends.

My Lords, I, too, am grateful to the noble Lord, Lord Walton, for providing us with this opportunity for a debate today. I want to talk about the ability of the NHS to learn from known weaknesses in healthcare delivery in order to improve significantly its productivity and efficiency. I want to follow up some of the points made by my noble friend Lord Woolmer and the noble Lord, Lord Mawson. I first declare my interest. I no longer have any appointment with NHS London, but I advise two companies with health interests—the General Healthcare Group and Perot Systems.

Since 1991, the NHS has had real expenditure growth averaging 5.5 per cent a year. That growth has been even higher under this Government. Never in its history has the NHS had such a sustained improvement in its resources and we have of course, as a number of noble Lords mentioned today, seen many improvements. However, now it faces a period of considerable retrenchment. How it conducts itself as a £110 billion a year business over the next year or so will influence significantly the available resources for research, translating research into clinical services and even medical education itself.

I do not intend today to get into a debate over which party will best protect public services, other than to say that being straight with the public is likely to pay better political dividends. I will take as my starting point, however, a quotation from the recent annual report for 2008-09 by the NHS chief executive, David Nicholson. I commend the report to the House. On page 47 of the report, Mr Nicholson says:

“We should also plan on the assumption that we will need to release unprecedented levels of efficiency savings between 2011 and 2014—between £15 billion and £20 billion across the service over the three years”.

I have a question for the Minister and, indeed, for the opposition Front Benches. Do they and their colleagues agree with the chief executive’s assessment of the scale of NHS retrenchment likely to be needed between 2011 and 2014? I suspect many people in the NHS would like to know where the political parties stand on that particular issue.

One of the best predictors of future behaviour is past behaviour. Applying this principle to NHS productivity and efficiency is not, however, reassuring, as the Office for National Statistics has shown. Despite NHS revenue nearly doubling in the past decade, and an investment of nearly £30 billion in capital assets, ONS data show NHS productivity falling consistently from 1995 to 2004. Only in 2005 and 2006 did it rise, a period when Patricia Hewitt and I were winning friends and influence in the NHS and getting into a considerable amount of trouble for energetically pursuing NHS reform and control over NHS finances and pay deals. After this period of challenging vested interests the NHS appears to have reverted to its old ways of falling productivity.

We are approaching a difficult time for public expenditure for whoever is in government, with high expenditure on debt interest, falling tax revenues and higher recession-driven transfer payments. Now is the time for the critical friends of the NHS to push for a bit of action on its flabbier parts, a kind of anti-obesity campaign with the NHS management of services. I start with another item from Mr Nicholson’s annual report on page 40. He says:

“While the NHS has had a good year, can we say we have done our best when 25 per cent of patients in hospital beds don’t need to be there and could be looked after by NHS staff at home?”.

It seemed to me, when I read it, a rather good question to which we need some answers before pouring too much extra cash into the NHS coffers.

Let me offer a few suggestions in my final remarks. The key to driving productivity and efficiency is for there to be a huge improvement in the quality of commissioning by concentrating the activities in a much smaller number of larger, more competent, bodies. It would also help to streamline the processes for changing unsustainable, often unnecessary, and sometimes downright dangerous, local hospital services. Simply buying more of the 35 per cent of spend that currently goes on fixed-price tariff items in local hospitals keeps services in those hospitals unnecessarily and will not remove unnecessary beds.

We have to drive the provision of healthcare outside acute hospital beds, more in line, I suggest, with the rather neglected 2006 White Paper, Our Health, Our Care, Our Say, which was based on a massive consultation with the public. Consolidation of specialist acute services, especially with the final stage of the European working time directive, which has already been referred to, is essential if we are to make services safe and effective for patients. I notice that my noble friend Lady Wall will be speaking. We need look no further than north London to see a large area with too many hospital services on too many sites consuming NHS resources that should be used for other health purposes.

I share the views of the Health Select Committee’s strong reservations about primary care trust commissioners. I remain unconvinced by the Government’s response to that report on this issue. It is not possible, or even, I would suggest, worth the effort, to try to produce 150 world-class commissioning PCTs. We simply will not get to the end of that journey.

To reduce our dependence on inappropriate hospital services, we have to improve significantly primary care and community services. From some of the work I initiated in London, I suggest a hefty dose of performance management and market testing on primary care trust community services. It could produce something in excess of a 25 per cent efficiency gain over time. The management of these services needs to be scaled up and improved, integrated better with GPs, social care and other services—as the noble Lord, Lord Walton, said—and far more effectively managed. I suggest that that could be done by using greater competition and new entrants to local markets. Personally, I do not care whether those new entrants come from the public sector, the private sector or from social entrepreneurs. I strongly suggest that the public do not care that much, either.

This approach is more likely to deliver the kinds of changes that the noble Lord, Lord Mawson, and others are looking for. I could mention other cases—pathology services come to mind, as do the management of estates, facilities and buildings in the NHS. The NHS has a footprint that is too big for the services it needs to provide. All these areas need to be looked at.

I end on this note. If we do not start to tackle these issues more energetically, as the NHS chief executive seems to be suggesting, it will be difficult to strengthen those areas that we probably all know need to be strengthened, such as the new dementia strategy, end-of-life care and adult social care. They have not had anything like the generosity of funding that exists in the NHS. All these Cinderella areas will be neglected if we do not tackle the issue of resources going unnecessarily into the acute hospital sector. I wish to finish with a quote from President Obama’s Chief of Staff. He said,

“it would be a shame to waste a good crisis”.

My Lords, I thank my noble friend Lord Walton of Detchant for introducing this important debate. But it is the patients who come top of my list of priorities, and their safety should be foremost.

Good quality of care, the correct diagnosis and safety at all times while in hospital are what all patients desire, and they need the same quality when they rely on their care being given in the community. First-class medical training is vital, and with many complicated conditions specialised training is essential. When the specialised units are linked with universities, this enables research to expand. There should be good communication and co-operation between the universities and hospitals.

A cousin of mine, Dr Tim Inglis, became frustrated when he found that this was not happening. He did not have enough time and freedom in the UK to do his clinical research for improving patient treatment. He is a microbiologist and is now working in Australia. He has undertaken interesting research and enjoys life. It is so important that we do not lose too many of our dedicated clinical researchers.

The noble Earl, Lord Howe, and I opposed the closure of community health councils. The Government, instead of building on them, set up the health forums in their place as a patient voice and support, only to close them down after two years. The Government then set up LINks, and this is the current situation. I quote from what they have said to me in an e-mail:

“Many of us have made supreme efforts to make the new LINks model work. LINks are now 14 months old and many have managed little at all of active oversight of health and social care. They have become bogged down in processes rather than outcomes and the so-called support from the Government has been passed from pillar to post, adding to the confusion and demoralisation. Events at Stafford have since come to light and there is real concern that other Staffords out there will go unnoticed in the current situation”.

I declare an interest as a vice-president of the Patients Association, which has been supporting the friends and relatives of the 1,200 people who may have died as a result of the poor care at the Mid Staffordshire hospital. Like many others, the association has been asking for a public inquiry.

Senior doctors who speak out against dangerous practices are being frustrated, or even bullied into silence, according to new research by the British Medical Association. Doctors and nurses claim that the current law is inadequate, and that whistleblowers need much greater legal protection if they are to prevent another patient safety disaster. An NHS trust has been accused of victimising an eminent paediatrician, who claimed that a baby’s death and at least 28 botched operations on children were caused by unskilled doctors. The consultant’s concerns were ignored by hospital chiefs—who then suspended him, saying they were concerned about the state of his mental health. However, his colleagues at the University Hospital in North Staffordshire say that the surgeon—a former adviser to the Healthcare Commission—was suspended for blowing the whistle over children’s safety. There must be better protection for patients, and for these people, who try to protect them from unsafe practices. I should be grateful to hear a response from the Minister. Or would she agree that there should now be a public inquiry into all hospitals in Staffordshire?

I must mention a very serious problem, which is the increase in the number of antibiotics becoming resistant to infections. There is an urgent need for new antibiotics—we have become reliant on them, and we do not want the infections to win. There is a desperate need for research and development on new antibiotics, which the Government may have to take the lead on. Could there be legislation to encourage investment for the pharmaceutical industry? This is beginning to happen in the USA—could the Government set up a working group to help this to happen here? It will be a disaster for future generations if they are without antibiotics.

A strong message came out of a seminar on diabetes that I attended last Thursday, with many experts present—that specialist nurses are an essential part of the best treatment and follow-up for patients with diabetes. One consultant from Ipswich had lost his specialist nurse, to his and his patients’ dismay. Specialist nurses are also as valuable a part of a team for treatment of stroke patients, as are physiotherapists and occupational therapists. Also the specialist nurses are so important for patients with epilepsy, dermatological problems, Parkinson’s disease, cancers and many more. They are an investment—not only do they support patients in hospital and the community, they teach other nurses and junior doctors, who so often do not understand the treatments of such patients.

Dehydration in ill and elderly patients is putting them at risk when they come into hospital, and so often one hears of neglect of these vulnerable patients. If one watches hospitals at five o’clock on a Friday evening, one will see staff pouring out of the doors. Over the weekends, patients are left with only essential staff, and little goes on. If only hospitals could keep fully working for seven days a week, so much more could be achieved, and patients would not be put at risk by getting dehydrated, if they cannot drink unaided. This can also be a problem in care homes, when residents are fearful they will be scolded by staff if they drink and then have to go to the lavatory. So they restrict their fluid intake, making them dehydrated, and that makes them confused and unwell. This area needs more research and guidelines. Perhaps this is something that CQC members could check in both hospitals and care homes so that patients and residents are kept contented and safe.

My Lords, I, too, thank the noble Lord, Lord Walton, for the opportunity to take part in this very important and wide-ranging debate. Like other noble Lords, I pay tribute to his career, which, when you listen to it being described, is astounding.

I declare an interest as chair of Barnet and Chase Farm Hospitals NHS Trust, which delivers healthcare across north London. I think that I am grateful to my noble friend Lord Warner for mentioning me and my contribution to the debate. He is always thought-provoking and controversial but very often right.

The NHS is a huge organisation with many facets and it is charged with maintaining the health of the nation—a huge responsibility. It is an organisation that is continually changing and adapting to new challenges. These range from new exciting treatments to the way in which healthcare is delivered, ensuring that the focus is on the patient, as referred to by my noble friend Lord Woolmer. Innovations such as same-day or short-stay surgery, minimally invasive surgery and major developments in the treatment of cancer have all come from the service’s ability to learn from research and experience and from feedback from the patients and their families and our staff.

My trust is a partner member of the NHS Institute for Innovation and Improvement and is actively engaging that organisation in a range of development initiatives aimed at improving patient care, such as the Productive Ward programme, Lean thinking, No Delays Achiever, patient safety and the Delivering Quality and Value strategy—all things that I think we would applaud.

An acute trust such as Barnet and Chase Farm has a major responsibility for providing safe and timely care to our patients. This is rigorously monitored to maximise the efficiency of the organisation in terms of access by patients into the system and I am pleased to say that the patient experience and the quality of care are increasingly being monitored. I say that I am pleased because that is exactly why we are there. The whole range of clinical governance tools are employed to do this, but listening to what patients and their families tell us is crucial to the ability of the organisation to learn from this experience.

The national patient survey feeds us with important information on how our service is viewed by patients. Their views may be very subjective, but we have to remember that their perception of the service is vital to our understanding and our ability to make changes to improve their experience. This, of course, may be in the form of a complaint, to which our organisation pays utmost attention—it views the whole process as a learning experience. Much work goes into training our staff in the handling of criticism and using that knowledge to improve our service.

In my view, one of the health service’s huge strengths is its total commitment to training and education. The term “lifelong learning” is embraced within the service for all grades of staff in both clinical and non-clinical areas. Through the process of appraisal, the potential of our workforce is identified and nurtured to the benefit of the service and of those who receive our services. There is a well used phrase—that our staff are our most important asset—and we should not dismiss that easily.

It also has to be remembered that the service trains the vast majority of staff who go on to work in the private sector and in many other settings both at home and abroad. It should be recognised that training goes on in virtually all healthcare settings and not just in teaching hospitals, although sometimes general hospitals worry that that may be the message that goes out. The challenge and debate that that brings to individual departments are very healthy in that they introduce innovation and change to enable the service to be fit for purpose. Training also develops the trainers in such a way that they examine their knowledge and practice regularly and keep abreast of modern developments.

Research and development has a key role in the service. Since the early 1990s, money has been identified within the NHS budget to foster and promote research. The Culyer report in 1994, to which the noble Lord, Lord Walton, referred, paved the way for research to become embedded in most NHS trusts, including my own, which is a necessary tool for the service to develop.

The nature of research in our organisation spans all disciplines, with some focusing directly and immediately on the delivery of healthcare. This system has recently been superseded by a network system of research-active organisations. They will promote the links between primary and secondary healthcare, along with academic institutions.

My trust plays an active part in our local network; indeed, it receives an income in recognition of the research activity undertaken, which helps to support the process and develop the culture of research. As I said when referring to education, research raises the quality of an organisation, enabling a culture that embraces change and innovation, which can only benefit the future of healthcare.

My noble friend Lord Warner will not necessarily agree with this, but the local hospital is an essential component of the local community. In my area of north London, which is populated by many cultures, religions and economic groups, it plays an important role. The equitable access to our service for all has a large influence on communities living together. We must now work hard to ensure that the services that patients need are the services that they get. We will continue working with local clinicians, residents, our patients and other partners to ensure that all improvements to local healthcare are sustainable, delivered smoothly and effectively and in the best interests of all patients.

In conclusion, the NHS is an overarching organisation that continually learns from its experience and its research to deliver the safe and appropriate care for which it was created.

My Lords, I am grateful to the noble Lord, Lord Walton, for initiating this debate and to be able to contribute, albeit with a great deal less knowledge than he has but with equal concern that, despite the relentless march and associated benefits of modern technology, healthcare delivery and social enterprise and cohesion are not as sophisticated or effective as they could be or should be.

Over the past year or thereabouts, I have had the privilege to chair an independent review of autism services for the Department of Health in Northern Ireland. My review team found that, despite a wealth of knowledge acquired, mainly by and through the voluntary sector organisations that have done some wonderful work over the past 20 years, throughout the entire period of direct rule in Northern Ireland there had been virtually no co-ordination, no command and control hierarchy and no structured pathway for autism. I believe that this deficit is overall of national proportions and I shall concentrate on this issue.

It appeared to me that the Hall and Elliman report, specifically the one known as the “Hall 4” report, in its conclusion that there was no foolproof method of screening for autism, was able to allow off the hook those who direct within the health service. Well, things have moved on. The team of professionals that I chaired has concluded that effective assessments of developmental progress are possible from around two years of age. That means in effect that, from January 2010 in Northern Ireland, 22,000 children aged two to three years will be screened each year.

One may ask whether that will be a massive and costly exercise, but that will not be the case. We already have in place—I assume that it is the same in Great Britain—a health visitor system, which over the past 60 years has successfully and willingly adapted to changing demands. It is eager to adapt and embrace up-training with regard to early identification of autism tendencies, which will be achieved at acceptable cost with the voluntary sector and departmental agencies working in partnership. Much of this is about efficiency gains.

In line with an expectation that roughly 1 per cent of the population is on the autism spectrum, we have calculated that 3 to 4 per cent of two years-olds will be queried, some 750 children per year in Northern Ireland. By assessing on the basis of population and with simple primary school maths, it will surely not be difficult to plan—largely, if not entirely, on the basis of the existing consultant provision—what is required to provide immediate early assessment and diagnosis. Each healthcare trust will know exactly what to expect and consultants can plan ahead, up-training themselves where necessary. They will refine the initial 750 children identified down to 1 per cent, which will probably be 200 to 250 children each year, who will from that early age be able to benefit from early interventions.

I come back to costs for a moment. We will be using almost the same professional practitioners, but in a way that is planned and structured better. Extra costs will occur but mainly in up-training, and those updated skills can be built into training programmes for those planning to enter the medical and associated professions.

Of course, that cannot be the simple end to my thesis. Children with autism spectrum disorder have to face transition to primary school and to secondary school and then they have to adapt to adolescence and so on. But is it not better to begin to learn to cope in the vital learning years between two and eight than for us to find a confused eight year-old with behavioural problems falling behind his peers and unable to adapt?

Here is the opportunity for progress, but it is not the end of the story. That is a matter for further adaptation and joined-up government. The Department of Health can break down the front door but every other department has to smooth the path that lies ahead: teacher training, police training, the Prison Service, sports clubs, the workplace and so on. I believe that each stage can be dealt with as effectively as we plan in Northern Ireland for the two to eight year-old phase. We do not have to reinvent the wheel; we do not have to tear down and replace existing administrative structures. We have to adapt to a reality that does not put our nation into and take it out of a series of disassociated stages. Life, especially for those with any disability, should be a gentle stream, not a series of waterfalls.

I conclude by asking the Minister and her noble colleague, the noble Lord, Lord Darzi, who has contributed so much, if they would look at the Answers that their department gave me on 20 May over the signature of the noble Lord, Lord Darzi, at col. WA 312, regarding the plight of those on the autism spectrum who find themselves in prison—perhaps up to 30 per cent of our prison population. It was simply not good enough to have an Answer that implied, “Prisons and autism we don’t do; we don’t provide; we don’t really want to go there”. Given the Minister’s diligence and given the noble Lord’s industry since he came into this House, I do not believe that that it is what either of them would want.

My Lords, I, too, congratulate the noble Lord, Lord Walton, on securing this debate and on his excellent speech—not a speech, a tutorial—on the benefits of and need for medical research. I am sure that the House appreciated it. It was ably backed by the personal story in the speech of my noble friend Lord Rodgers. I thank my noble friend Lord Addington for reminding us that we should be thinking about a national health service. He reminded us that prevention is better than cure. I would add that my noble friend is not overweight; it is all muscle.

The National Health Service today is a strange organisation. It is neither totally planned from above, nor does it free its patients to obtain treatment and care from any health facility, public or private, that they wish. It is something of a muddle and rather confusing. It is leading to a lot of fragmentation and confusion. I shall illustrate the law of unintended consequences in some of the things that are happening in the health service, especially in medical education and research. Teaching and research used to be done primarily by the academic workforce in medical schools, medical faculties and the teaching hospitals, often in collaboration with doctors and physiologists in the non-teaching hospitals and using all the extra clinical material in those places. However, between 2000 and 2007, there was a fall of 27 per cent in the medical academic workforce. There are now only 2,937 academics working in our hospitals, medical schools and universities. Despite that, there has been a huge increase in the number of undergraduates: a 50 per cent increase in the number of medical students in the past 10 years, which is hugely welcome. The student population is currently 30,000, excluding all the postgraduate students, but that means that there is only one medical academic working in this country per 100 undergraduate students.

As a result of the decline in academic staff, there is more pressure on clinical staff in hospitals to teach and do research, but managers of those hospitals are often interested only in data collection, patient throughputs, targets and waiting lists. Teaching and research are very low on their radar screens and we heard from the noble Lord, Lord Warner, that PCT commissioning is questionable at times and does not always consider research and education.

We also need to look at a few other reasons for the demise of medical academics. The noble Lord, Lord Turnberg, mentioned bureaucracy. One would expect a Government that managed to deregulate the City in such a dramatic and fantastic way to be able to do something about deregulating medical research. We must remember that there is not pay parity between clinical and academic staff. Newly qualified doctors have huge debts. Medical students have a longer training and it is full time, so they cannot take part-time jobs to help pay their fees and debts when they qualify, so they are more likely to want to go into medical and clinical training and get on the ladder quickly to earn a decent salary as clinical staff than to spend time doing academic work or research.

I raise the question also of women in medicine. I am delighted that most medical schools now take in more women students than men. This is excellent news for women, who are eminently suited to a medical career. However, they, too, may be in a hurry to get their higher qualifications. They may want to earn money not only to pay off their debts, but also perhaps to pay for childcare in future; so they may reject medical research and get on with clinical work to earn a higher salary. Is the NHS doing any research to analyse the hopes and aspirations of the women doctors who are qualifying and are their circumstances being taken into consideration for properly planning the workforce in future?

Another factor is the private finance initiatives. Polyclinics and new health centres were mentioned by one noble Lord. The noble Lord, Lord Mawson, mentioned the integration of social care—how I wish that we could have integrated health and social care. Polyclinics would be an ideal place. However, no private developer will want to waste money on facilities for teaching and research. He will want a return on his money, and it will be much more difficult to make a profit if there is social care as well as teaching and research going on in an establishment.

I read something interesting about contracts with the private sector and commissions for routine surgery that are often taken out by PCTs. I read about a gastroenterologist who had his entire endoscopy list taken away from him without being consulted by his managers. The endoscopies were to be done by a private hospital, away from the main hospital. Most of his research and teaching of students was based on how endoscopies should be done and what he was discovering. When that sort of thing happens, it is crazy and counterproductive.

In conclusion, in the past 10 years the National Health Service has improved beyond recognition. Many new facilities have been built and a great deal more equipment supplied, along with more doctors and nurses—I do not have to recite the Government mantra for them. Everything has improved hugely. We know that quality is an issue, but the noble Lord, Lord Darzi, is addressing that. Surely the challenge now is to make sure that medical education and research go on being the best in the world, as they have always been. They must not fall behind because we are concentrating on profitability, efficiency and patient throughput. We must remain the best in the world for medical research and education.

My Lords, I, too, thank the noble Lord, Lord Walton of Detchant, for initiating this important debate and for introducing it in such a lucid and informative way.

The report Best Research for Best Health stated that the objective of Her Majesty’s Government is to ensure that patients benefit from clinical research, that areas of unmet needs are addressed and that the health of the people is improved. Bearing in mind these worthy objectives, I will examine how they relate to the greatest hazard that threatens millions of people in the UK. I refer to the obesity epidemic, which is increasing all the time and represents a dangerous threat not only to the nation’s health, but also to the NHS and to the economy as a whole.

Evidence-based medicine is quite rightly the best basis for the practice of medicine, but sometimes lobby groups position themselves between science and good evidence-based practice. The food industry has concentrated on the lack of exercise as the cause of obesity, which of course suits it very well because, understandably, it does not want any reduction in its trade. The science is clear: if one wants to take a pound of weight off by exercise, one has to run a mile; whereas simply reducing the number of calories eaten or drunk is guaranteed to reduce weight. Exercise is very good for the integrity of the cardiovascular system and is effective in reducing the wrong sort of cholesterol. There is also evidence that exercise helps in reducing the amount of fat in a patient’s body, rather than a reduction in muscle. But that is when exercise is combined with a reduction in the number of calories, as the noble Lord, Lord Addington, knows well. It should be emphasised that one can put on weight just by drinking fluids. Let us take, for instance, the cocktail, Mai Tai: three such cocktails provide 1,000 calories.

In a predominantly sedentary population such as ours, it is clear that exercise is not an efficient method of weight reduction. In fact, many obese adults are precluded from exercise by problems such as arthritis, heart disease and respiratory inadequacy. The emphasis on physical activity has political supporters, however, as there are fewer commercial interests opposing the message and it fits with the promotion of events such as the 2012 Olympics. The alternative message, which proposes a move towards healthier diets and reducing the consumption of energy dense foods, such as fatty snacks, confectionary, soft drinks and so on, is much more sensitive politically. A man who was confined to an electric wheelchair and therefore could not exercise decided to reduce his weight by two stone, or 13 kilograms, which he did in a rather revolutionary way. He simply ate less and quite soon he came down to the size he wanted.

There are a number of red herrings in this subject, including brown fat, big bones and hormones, but at the end of the day we are what we eat. An overweight man consulted me about his excessive weight and he assured me that he had tried every diet in the book, but without any effect. He asked whether I could help. I noticed that his wife was quite thin—perhaps I should say she was a normal size. So I suggested that he ate the same quantity as his wife. He saw the danger of that and was somewhat reluctant, but he agreed to give it a try. Three months later when I inquired of his wife how successful this regime had been, she said, “It has been a disaster because I’m putting on weight”.

Danish doctors have reported that a British formula- based diet was successful in reducing the weight of their patients by more than 12 per cent, which gave very good symptom relief in obese men and women with arthritis of their knees. One hundred and ninety two of them followed a 500 calories a day or an 800 calories a day diet for eight weeks and were maintained on a stabilising diet for about six years. On average, the patients weighed 16 stones and lost two stones in 16 weeks, and 60 per cent had a significant improvement in relieving their symptoms, especially pain in their knees.

Professor Bliddal from the Parker Institute, Frederiksberg Hospital, commented that obese patients have very bad knees and if they exercise before losing weight they almost certainly wear the knees down and make things worse. In his programme people lose weight first and when they are a lighter weight, they usually regain their former activity. He ends by saying that bad knees are no excuse for failure in losing weight.

Those who insist that exercise is the solution to the problem of obesity give obese patients just the excuse they need to say that they cannot exercise to lose weight. They remain in their morbid and eventually fatal outcome. Yet there is some comfort for those obese people who find it difficult to lose weight. A strange mechanism in the brain is relevant in weight control. As one’s weight increases, a complex brain regulatory system adapts to lock in to the new, heavier weight. It becomes the new level which the appetite and activity control centres then try to maintain. This explains why some people have difficulty in reducing weight. Even so, they can still lose weight if they diet.

I have so far dealt with adult obesity. As the noble Lord, Lord Addington, mentioned, we need a different approach with children, one combining a reduction in calories with increased activity and counselling. At the same time, all children have to be encouraged to be much more active: walking or cycling to school, plenty of games and reducing the amount of TV and computer pastimes. Prevention is much better than trying to cure the obesity when it occurs. The culture has to change radically if the nation’s health is to improve.

Life today is such that we need to eat 500 calories less than was the case. The food industry has got to produce new, mainstream foods with far lower calorie densities. At the start of the last war, one-third of the British people were either underfed or ill-fed. The introduction of food rationing changed that within a few weeks. That was the greatest public health experiment ever. We cannot put the clock back but we must have voluntary change. This can be helped if Her Majesty’s Government in particular and politicians in general accept what research has already revealed: we are what we eat and there are no mysteries.

I have forgotten to declare an interest. When a person tells me that I am lucky to be thin, I am tempted to say “Actually, I am normal”. As that might be construed as a criticism of his obesity, I explain that I cannot claim any credit for being the size that I am. It is all due to a patient of mine 40 years ago. I was on my way to a black-tie dinner wearing the black-tie outfit belonging to my father-in-law. It was 50 years old and green round the edges. I was called out to St Bartholomew’s Hospital to see a lady who was bleeding to death from a tumour in her groin. I went up to the bedside. To my amazement she seized hold of my jacket and said, “That jacket is very old”. I said, “It is 50 years old”. She said, “It looks it.”

I did not quite know how to cope with this. There was this lady dying yet joking away. She said:

“Now, look. I know I’m dying. I know there’s no hope and it’s inoperable. But I want you to take me to the operating theatre and have a go. Take a risk and try to remove this tumour. You will have to put a new artery in”—

she knew her medicine.

“I am in the cloth trade in the East End and if I survive I will make you a new black-tie outfit”.

I was amazed to hear this. I operated all that night and because she was indestructible she survived eight years. During that time she made me a new suit.

As a tribute to her, I have to stay the same size. As I am Scot I do not want to buy a new suit. We are what we eat.

My Lords, it is a pleasure and privilege to be responding for the Government to this debate. I am grateful, as other noble Lords clearly are, to the noble Lord, Lord Walton of Detchant, for initiating it. If nothing else, it has been wide-ranging—a veritable potpourri of contributions. I hope I will be able to address all the themes and individual issues. I confess that I have a large pile of notes in front of me and it may be necessary to write to some noble Lords, for which I apologise in advance. I will do my best.

I turn first to health research. The Government fully recognise that a vibrant and well-organised health research sector is of enormous importance to our healthcare system, to our economy and to countless individuals and their families. That is why we have the radical and ambitious health research strategy that the National Institute for Health Research is delivering. That is why funding for all aspects of research has been increased to the highest-ever levels and why the place of research within the NHS has been given renewed emphasis. We hope the combination of our strategy and the growth in funding is powerful. No one can fail to be struck by the progress that the NIHR has made or by the efforts being made under Sir John Bell and the Office for Strategic Co-ordination of Health Research in invigorating translational research.

What we are beginning to achieve through that research—through what the OSCHR partners are doing together—is, as several noble Lords have mentioned, unequalled anywhere else in the world. We are doing it by building on, and in no way diminishing, our strengths in basic science. That much and a great deal more are clear from the progress report that the chairman of the OSCHR published last November.

Progress is unquestionably what the NIHR—I apologise for using initials—has achieved. The energy and determination which so many people in the Department of Health and the NHS have put into implementing Best Research for Best Health has enabled enormous strides to be made. The evidence is clear in the positive impact that the new funding regime is having on all parts of the research community and across the NHS. It is clear from the impact of the clinical research network on the numbers of trials taking place in the NHS and the scale of patient recruitment to them. It is clear from the effect of bringing together and supporting the people who conduct research in the NIHR Faculty.

We want a research-intensive NHS. It is good for patients and, as the noble Lord, Lord Walton, rightly said, it is good for clinical teaching at all levels and across disciplines. The quality improvements and innovation that lead to productivity gains and better patient outcomes depend on the new ideas that research generates and evaluates. We recognise the need for vitality, which was mentioned by several noble Lords, including the noble Baroness, Lady Tonge, who correctly said that we have to remain at the top. Clinical fellowships and lectureships provide research, exposure and experience for academically gifted medical and dental trainees. We are moving to the stage where there will be some 750 academic clinical fellowships and 400 clinical lectureships in the NHS, which is equivalent to more than 2 per cent of all hospital doctors in professional training.

We are uniquely placed in this country in the scope the NHS offers as a base from which to conduct clinical trials. We and our research partners in industry and the charitable sector believe that we have the right policies and right structures to capitalise on that potential. There are of course challenges internationally and at home to the full realisation of that objective, but I do not believe that the European clinical trials directive—mentioned by several noble Lords, including the noble Lord, Lord Walton of Detchant—is one of them. The total number of clinical trials in the UK has remained stable since the introduction of the directive and we continue to be at the top end of the European league table in our sponsorship of both commercially and non-commercially funded trials. If we are to remain there, and to face the international competition, we need efficient, robust and, above all, transparent ethical and governance systems. I shall return shortly to the points raised by my noble friend Lord Turnberg on those issues.

Real and considerable effort is being made in this area. We are making our research ethics committee structure simpler and stronger and integrating it more closely with other aspects of research regulation. We are simplifying and streamlining the administrative and regulatory procedures governing trials and other studies and updating our research management systems.

The noble Lord, Lord Walton, mentioned research charities and their excellent umbrella organisation. The support we give those charities is as important to them as it is to us. The clinical research network now provides automatic infrastructure support for all eligible trials, and the 2004 science and innovation investment framework committed the Government to underpin the charity-funded research undertaken in our universities. This investment is made through the Higher Education Funding Council for England through its quality-related funding stream and will rise to £194 million in 2009-10.

The noble Lord, Lord Walton, also raised the issue of the European working time directive. There is no evidence that greater numbers of trainees are failing in their end of year assessments where 48-hour working has been introduced. No junior doctor can become a consultant until the appropriate royal college has issued a certificate of completion of training. This is an essential safeguard ensuring that medical training remains of the highest standard. Given the concerns raised by some professionals, we have listened and acted. The former Secretary of State for Health announced a review on the impact of the implementation of the European working time directive on 20 May. This review will consider concerns that the introduction of a 48-hour working week may have a detrimental effect on junior doctors’ training, particularly on the training they receive while at work. It is important that there is an independent and objective assessment of whether the introduction of the directive fully into the NHS will necessitate changes to the current system of postgraduate medical training.

I shall address the issue of social enterprise as part of these remarks and then return to the individual points raised by noble Lords. I feel that I should declare an historic interest, as it were, as the founding chair of the Social Enterprise Coalition and as someone who has been working with social enterprises and co-operatives almost all my working life. I believe that social enterprises can make a big difference to the lives of the people and local communities they serve. We agree entirely with the noble Lord, Lord Mawson, that they are able to transform the way services are delivered and to improve health outcomes. Innovative and flexible solutions to transform health and social care can be found in social enterprises and they have strong potential in other sectors, such as housing, leisure and transport. That is why encouraging social enterprise in health and social care is a key part of our patient-led reform of services.

The department is actively promoting social enterprise in health and social care through the Social Enterprise Investment Fund and by supporting the next stage review commitment for the staff’s right to request. The Social Enterprise Investment Fund has so far provided £20 million of funding to 200 social enterprises and the new fund manager is working to build on this success to support even more. The fund offers a range of financial services, including grants and loans, as well as providing business support tailored to the needs of social enterprises in various stages of development.

In addition to evaluating the impact of these investments, the department is working with the Office of the Third Sector to pilot the social return on investment. We are working with six social enterprises delivering mainstream health and social care services, to measure the social value that they are bringing to their local communities. The department’s investments include funding for several healthy living centres, such as Well UK, Community Docs for All and St Luke’s Healthy Living Centre. These centres address local health inequalities and improve access to services for the local population, making a real difference to local communities. The right-to-request commitment in the next stage review is enabling clinical staff in primary care trusts to use their entrepreneurial and leadership skills to develop innovative services to improve service provision for their patients and their local communities and we are very committed to that programme.

The noble Lord, Lord Mawson, raised the issue of social enterprise and expressed his frustration. He is correct that we have yet to crack the need for holistic commissioning and he knows that I am a great champion and supporter of this issue. He knows that it works and there is no doubt that we still have to crack the issue of rolling this provision out. We are committed to encouraging commissioners to grasp the opportunities offered by this sector. For example, Manchester PCT has commissioned the Big Life Group to run the Kath Locke Centre, a primary care centre in Moss Side. The centre allows local people to access services and to help deliver them. We have published two documents that we hope will help local commissioners to crack this.

I take issue with the noble Lord about polyclinics being based on a biomedical model. One of the largest community-owned health organisations is Local Care Direct. It was set up to provide out-of-hospital care to 2.5 million patients in Yorkshire and Humber. Being a Yorkshirewoman, I am particularly fond of this organisation. Local Care Direct was the first organisation to open one of the new GP-led access centres nationally in December 2008. These services complement existing GP and out-of-hours services in the area and demonstrate how a social enterprise can help transform primary care.

I pay tribute to the noble Lord, Lord Mawson, for the work he has been promoting on healthy living centres and I hope that I can help him to crack the bureaucracy. He is quite right that getting bureaucrats to be entrepreneurial and to recognise the benefits of social enterprise is a major challenge, and that is clearly what we have to crack. He is absolutely right to make that point.

The noble Lord, Lord Walton of Detchant, mentioned academic health science centres. These bring together a small number of health and academic partners. The aim is to help speed up the process of translating developments in research into benefits for patients and the local community, and to promote the adoption of their discoveries within the NHS and across the NHS and the world. Designation is awarded for a period of five years and the successful centres will be subject to review. The international panel of designation recommended that there should be a reapplication process. The Secretary of State has accepted this recommendation and he also reserves the right to suspend or remove designation if that is deemed necessary.

The noble Lord asked about the 1.5 per cent research spend. The Government have made unprecedented increases in funding for health research. Total government investment in health research will be £1.7 billion by 2010-11, an increase of more than £290,000 in the three-year period covered in the 2007 Comprehensive Spending Review. There is no evidence to suggest that a particular proportion represents a right level of support to aim for. We need to aim to make that investment work for us and to make it as effective as possible.

The noble Lord raised the issue of MTAS. Since the old system was abolished the Department of Health has worked with the medical professions at various levels to design the best possible recruitment system for doctors in training. Nearly all the deaneries use the same IT system for their local recruitment. National recruitment has continued to improve. The establishment of Medical Education England represents a unique opportunity to work with professions and get the right number of staff in the NHS, at the right level.

My noble friend Lord Woolmer was correct to mention the next stage review and made a good point about patients’ needs and experience and how they should inform how services are organised. I will address funding issues in a moment. He also made the point about more clinicians in leadership roles. Clinical leadership is key to the future success of the NHS and the National Leadership Council has been established to support the service delivery in this.

The noble Lord, Lord Rodgers, raised the issue of stroke, as did several other noble Lords including the noble Lord, Lord Walton of Detchant. He was right to point out that we have a new national framework for stroke and we are endeavouring to give it the right kind of emphasis and prioritisation that stroke requires. I can confirm that the 10-year plan is on track, that the stroke strategy acknowledges that the networks are of great benefit and that all the stroke services in England now fall within one of the 28 networks. The work of the stroke improvement programme, including the networks, will be evaluated over the next year, after which future work plans will be considered.

The noble Lord also asked about research. The NIHR clinical research network is building on the extraordinary success of the cancer research network to maximise the potential of the NHS to support clinical trials and involve more patients in them. The stroke network, to which the noble Lord referred, is one of six topic-specific networks and well over 200,000 people were recruited into studies across the whole network last year. Among other things, the result is an increasing integration of research and patient care, about which the noble Lord was concerned. The noble Lord asked where he could find out about the cost of the stroke research network. Improving the level of quality of research provides new opportunities for stroke research in the NHS and the integration of research within the delivery. There is a commitment of £20 million over the next five years that has been made to support the UK stroke network. That does not answer the question about where you find that information and I undertake to write and tell the noble Lord. It says that we are doing it, but not where you find the information, for which I apologise.

My noble friend Lord Turnberg talked about regulation, data sharing and the DIPEx website. He asked whether we could have another go at bureaucracy busting. We are redoubling our efforts to reduce bureaucracy and are fully aware of his and other concerns. We are working with Professor Paul Stewart in Birmingham on these issues and others and taking practical steps to include the creation of an integrated research application service. This is transforming the application process. Single application forms are necessary and we want to move towards a much simpler way of proceeding. We are doing our best to do that and my noble friend makes a very good point. On DIPEx, the NIHR is the main funder of the DIPEx database that the noble Lord mentioned enthusiastically and I undertake to look at it myself.

The noble Baroness, Lady Emerton, as usual made a very well-informed speech about the importance of building community cohesion—High Quality Care for All being the beginning of the revolution not the end. I am pleased that the noble Baroness is serving on the commission that the department has established. The former Secretary of State announced a review of the impact of the implementation of the European working time directive on 20 May, which is an issue that the noble Baroness mentioned, and I hope that I have answered that question.

The noble Lord, Lord Bew, gave an important and eloquent description of how the NHS coped during the Troubles and I join him in paying tribute to NHS staff at all levels during that period.

The noble Lords, Lord Addington and McColl raised the issue of obesity, which we have discussed in your Lordships' House within the past week or so. I would say to the noble Lord, Lord Addington, that we are working across government. Change4Life and the Olympic legacy show that we are fully aware of the need for people to walk, cycle, swim, dance in their bedrooms and take exercise. We have policy documents to deal with that and they are rolling out across government. The noble Lord, Lord McColl, gave us an important master class of good sense on the prevention of obesity. The only thing that I would add is that we are leading development in obesity research strategy across government, with a strong emphasis on prevention.

I need to deal with the issues raised by my noble friend Lord Warner. He asked about a speech made by the head of the NHS. That text was agreed and cleared with the then Secretary of State. It started with what we know: that PCT allocation will grow by an average of 5.5 per cent each year 2009-10 to 2010-11. It then sets the scene that although we do not know what the spending review settlement for April 2011 will be, we at least know that total public spending will slow significantly and large productivity gains will be needed to cope with the rising demand for health and social care systems. The argument is that unprecedented productivity gains can be made only by improving quality.

My Lords, I was not quoting from the speech. I was quoting from page 47 of the NHS chief executive’s annual report. I was asking whether the Government had endorsed that. If my noble friend says that the Secretary of State approved the text, I will be reassured.

My Lords, he did indeed. My noble friend will know from his own experience that that would certainly be the case.

We know that we need to get better care delivering better value. There will be great efforts within the NHS to tackle, for example, healthcare associated infections. We estimate that we have already saved £75 million in reduced bed days and drug costs, while improving outcomes for patients. I have quite a large amount of information about the costs and savings that we are seeking to make, so I will write to the noble Lord because I am probably running out of time.

The noble Baroness, Lady Masham, raised the importance of the patient’s voice, the issue of Mid-Staffordshire and whether we should be having a public inquiry. We are unconvinced at this time that a public inquiry would add anything to our understanding of what went wrong in that hospital and what needs to be done to prevent such events happening again.

My noble friend Lady Wall again pointed to the importance of listening to patients and the use of patients’ feedback to inform change and progress. Her remarks were relevant and supportive. The noble Lord, Lord Maginnis, raised the issue of autism. I pay tribute to the noble Lord’s pioneering work on autism. We have discussed this in your Lordships’ House in the past. I hope that we will see the noble Lord participating in the forthcoming discussion on the Private Member’s Bill on autism which is about to come to your Lordships’ House.

The noble Baroness, Lady Tonge, made a wide-ranging speech, which included a pop at some of the issues that she is concerned about. She recognised that there has been significant improvement. I undertake to write to the noble Baroness about women doctors and their aspirations.

We have run out of time. I hope that I have at least nodded in the direction of all the issues raised by noble Lords. This is the last Thursday of debates in your Lordships’ House before we enter the time of trying to complete the Government’s legislative programme before Parliament rises in the autumn. It is entirely appropriate that the Cross Benches chose these subjects for debate and that they were of such high relevance and interest. I thank noble Lords for their contributions.

My Lords, I am extremely grateful to the Minister for that remarkably comprehensive and detailed analysis of the speeches that we have heard today in this very wide-ranging debate. I became a Member of your Lordships’ House 20 years ago. Not long afterwards, I was successful in obtaining a Cross-Bench debate, surprise, surprise, on the National Health Service. At the end of that debate, I tried, valiantly, to comment upon all of the contributions that had been made during the debate. As I attempted that I was roundly rebuked by the Minister on the Front Bench and told that was not appropriate in these circumstances. I have learnt that lesson. Hence, I am not going to say more, except to thank everyone who has contributed to a debate that has covered an enormous range. It will repay reading because so many invaluable points were raised in the many contributions today. I beg leave to withdraw the Motion.

Motion withdrawn.