My Lords, I beg to move the Motion standing in my name on the Order Paper and to say how delighted I am to initiate this debate today, especially following the Government’s commitment last week to protect health spending. As the Chancellor of the Exchequer said, in presenting the Government's spending review:
“But to govern is to choose, and we have chosen the national health service”.
We would do well to remind ourselves that the Chancellor also said:
“That does not mean that we are letting the Department of Health off the need to drive real reform and savings from waste and inefficiency. Productivity in the health service fell steadily over the past 10 years, and that must not continue”.—[Official Report, Commons, 20/10/10; col. 959.]
Nevertheless, overall NHS spending will increase in real terms over the course of the spending review period, and it is right that we should now have the opportunity of setting out the views of this House on the Government’s healthcare plans. Their proposals to put patients at the heart of the NHS, to bring greater focus on clinical outcomes, and to empower health professionals are set out in detail in the White Paper and in all the consultation papers and announcements that have subsequently been issued.
Every Government must grapple with concerns over medical research and screening, accidents—especially in the home—obesity and smoking, to name some of the more perennial concerns. The impact on children’s health of all those arguments over MMR and the fallout from the last Government’s handling of the swine flu epidemic have also emphasised the central importance of vaccination to government health policy. I very much hope that my noble friend will give further details as to the Government’s approach to this critical area.
Before I go further, I need to declare my interest. For several years, I was ultimately responsible for the National Health Service in Wales, and my ministerial team and I worked closely with John Wyn Owen in developing our clear policy,
“to add years to life and quality life to years”.
I should also remind the House that for 41 years I have been a partner in the national commercial law firm Beachcroft LLP.
Many of the Government’s commitments will require primary legislation, and a Bill is due to be introduced later this year which will attract considerable attention not only from within the NHS but from firms in the private health sector and from professional advisers. As a former science Minister, I was particularly pleased with the generous treatment of the science budget, which will also enable the investment of £220 million in the UK Centre for Medical Research and Innovation at St Pancras, and also to fund the Laboratory of Molecular Biology in Cambridge.
The programme set out by the Government is undoubtedly an ambitious one, particularly in its vision of patient-led healthcare. Few will dispute the merits of giving patients more choice and control. Much debate has already focused in this respect on the shift of responsibility for commissioning most healthcare services in England from primary care trusts to local consortia of GP practices. This is intended to bring decision-making as close as possible to patients, in what the Government terms,
“no decision about me without me”.
Much has been said, and will continue to be said, in relation to the proposed role of GP consortia, on the challenges that this will present to GP practices and other stakeholders involved in commissioning; and the support which GPs will need to commission services and contract with service providers effectively. However, these discussions should not blind us to the fact that the Government’s commitment to giving patients a choice of any provider, choice of consultant-led team, choice of GP practice and choice of treatment alone will entail more sweeping changes to how the NHS operates, much more sweeping than many commentators thought only six months ago.
As president of Case Management Society UK, I would like to stress the contribution that case managers can make to the better allocation of resources, and also to the creation of more joined-up treatment for patients. I therefore hope that we shall see an expanded role for case managers as the NHS evolves. As experts in the process of communication and co-ordination, case managers can help patients who have to make informed decisions about their individual healthcare and also provide an opportunity to shape the future of healthcare services.
“Choose and book” has already greatly enlarged the degree of choice that patients or their GPs can exercise in relation to their treatment. The emphasis on the choice of named consultant-led teams for elective care by April 2011, when clinically appropriate, will be a very positive development, and one supported by the Royal College of Surgeons, which has briefed us for this debate and which is helping to lead the way in developing and using outcomes data. I know that my noble friend and his colleagues are rightly concerned to ensure a genuine level playing field for providers of care. Ultimately, effective and fair competition under a rules-based system will stimulate innovation, bring forward extra capacity and underpin genuine patient choice. Notwithstanding the statements of the Secretary of State’s predecessor in favour of the NHS as preferred provider, many privately owned operators already provide additional capacity through the Extended Choice Network. As a means of using all available beds and resources to assist in the major task of improving the NHS, this framework has been a success for patient, taxpayer and private sector alike. I understand that the coalition Government are planning to build on this framework in rolling out the new “any willing provider” framework.
The creation of a level playing field will require not only a focus on high-profile initiatives such as the right to choose a consultant-led team but a detailed attention to the minutiae of commissioning. The duration and termination provisions of the contracts which are rolled out under the framework, the way in which these contracts are awarded and the number of separate contracts that providers will need to bid for and perform may in practice have as much impact on the creation of a level playing field between providers as some of the more publicly debated issues. Of course, plurality of supply in the NHS will need to go hand in hand with a regime for the so-called failing hospitals. This is an area of great complexity from a policy, financial and legal perspective, but one which I hope that the Government will not shy away from in setting out their reform proposals in more detail. We must ensure that patient choice becomes a reality for all patients.
Patients will need access to information, and I welcome in this context the Government's proposals to centralise all data returns in the Health and Social Care Information Centre. Informed choice will be about recognising the importance of providing more insightful information to patients, but also that,
“different people and groups in society access information differently and need it presented in different ways. We must ensure the right information is available and presented in a relevant way to those who could otherwise be excluded”.
My noble friend has rightly characterised these plans as requiring an “information revolution”. That brings me to clinical outcomes. Few members of the public or the medical and nursing professions will disagree with the Government’s aims to hold the NHS to account against clinically credible and evidence-based outcome measures and remove process targets with no clinical justification. The public will surely welcome their proposals that payments to providers should reflect outcomes, not just activity, and provide an incentive for better quality. The same is true of the plans to pay drug companies according to the value of new medicines and with a view to ensuring better access for patients.
The Government’s focus on excellence in the NHS emphasises that there is a lot more work to be done to ensure consistently excellent performance in all areas of care. This is about more than just enshrining duties into law; it is about ensuring that the drivers of excellence in the NHS are identified, implemented and promoted.
One area is, of course, cancer treatment. I know that my noble friend Lady Finlay of Llandaff will on 11 November give us all an opportunity to debate the measures necessary to improve the quality and quantity of life for people with cancer, so I will not say anything further on that—although the Minister may want to say something further.
It would hardly be possible to comment on the setting of new quality standards in the NHS without paying tribute to the excellent work of the National Institute for Health and Clinical Excellence. At a time when the future of certain valuable arm’s-length bodies remains uncertain, the steps which the Government are taking to ensure the independence of NICE and its core functions are encouraging. Of course, the Government have also indicated their intention to empower professionals and providers, give them more autonomy and make them more accountable to patients through choice, and to the public through more formal means of accountability. I read carefully my noble friend’s speech to the King’s Fund. He said, “It boils down to trust”. How right he is.
GP consortia will be accountable to the proposed new NHS commissioning board and it must be the clinicians and their patients in consulting rooms and clinics, not the board, who are the so-called “NHS headquarters”. The independence of this board will deliver on the promise of taking political micromanagement out of the NHS that so many Ministers have made in this House, but few, sadly, have been able to honour.
Nor will this promise be honoured in just the commissioning of care. The same degree of independence will be given to Monitor in its new incarnation as the economic regulator of healthcare providers. Several of my colleagues may well want to refer to that. We of course need greater autonomy at the operational level, and colleagues may recall the strong reservations of my noble friends regarding the constraints imposed on all those powers given to, for instance, foundation trusts. We had doubts about the constraints imposed on the freedoms that were originally promised. As part of the Government’s commitment to,
“create the largest and most vibrant social enterprise sector in the world”,
foundation trusts will at last be given those greater freedoms. My goodness, they are going to need them, and we await those further announcements with great interest.
In conclusion, I recognise that there is a place for effective performance management in the NHS. This has yielded promising gains in productivity in some regions, such as the south-west. Handing more freedom to our successful foundation trusts will be the key to unlocking greater innovation in the NHS. We also welcome the additional responsibilities which are to go to local authorities, and we will be monitoring those very carefully. This will all require investment in infrastructure and a clear focus on the management of NHS assets, informed by the skills of those organisations with particular experience in the field of asset management. The White Paper does not outline in detail what will happen to, for instance, the LIFT schemes to which primary care trusts are party. This is clearly an important area, as well as one that is ripe for fresh thinking. We look forward to hearing from my noble friend on that.
My noble friend’s task in bringing these reforms to fruition will be daunting. These are the most important reforms to the NHS since 1948. It is critical that we get them right and move the debate from one about structures and processes to one about priorities and progress in health improvement for all.
My Lords, I congratulate the Government on a wonderful, beautifully written document—the White Paper, Liberating the NHS. Finally, the NHS is to be freed. The document’s honeyed tones and warm aspirations are sweetness and light. Its expressions of good intentions will easily deceive less well informed readers. However, to leave aside the aspirations, to which I shall return, the one thing that the NHS does not need is another reform. That is why in opposition Mr Cameron promised to halt the merry-go-round of organisational change with which the NHS had been previously inflicted. This promise was countersigned by a pledge by Mr Clegg, the Deputy Prime Minister.
I have absolutely no desire to embarrass the noble Earl, Lord Howe, for whom I, like so many of us, have genuinely a huge regard, but we have already learnt how trustworthy this Government as a whole are. So this merely minor change—no merry-go-round—means a reorganisation in which all primary care trusts are to be liquidated, all hospitals will become foundation hospitals, strategic healthcare authorities are to be abolished and the responsibility for public health will become part of the remit of local authorities. This does not seem to be so minor after all—more of an amazing big dipper. In this battle for the NHS, more than three-quarters of the £100 billion NHS budget will be devolved to general practitioners for administration.
Over the past few months, we have heard a great deal about the legacy left by the previous Government. Forgive me if I feel angry at this; it is not often that I do and seldom have I felt as angry. The negative tones have been the cornerstone of an excuse for the severest cuts in public spending in living memory. This Government’s pronouncements, on the whole, are not to be trusted. If their pledges on the NHS reforms are void, so are their promises on the ring-fencing of NHS funding. If we want to consider a legacy, perhaps we might recognise that the Labour Government left the NHS in its healthiest state for decades—a position that this Administration have inherited.
In spite of the Government’s assurances, the NHS is already being cut. Managers have been told to find £20 billion in efficiency savings if widespread closures are to be avoided. To give just one other example, in London the deaneries are threatened. Perhaps the Minister can confirm that, where so much healthcare is needed and where the cream of our young professionals is trained, junior hospital posts are facing a cut of 14 per cent next year. As I understand it, 70 key training posts in general medicine out of a total of 300 are to go—perhaps the Minister can confirm this—and another 70 posts from the other specialities are to be cut by 2014.
If the King’s Fund has calculated correctly, the reorganisation will cost the NHS between £2 billion and £3 billion, which will be taken from patient services. Consider this for a moment: the pressure of population change, the incidence of chronic illness, the rising age of our population, inflation and the rising expectations of patients mean a real cut in resources. The biggest problem will almost certainly be in chronic care. The massive cuts proposed in social care and welfare services will inevitably result in increased pressure on what we can now see is becoming an already underfunded NHS.
What about research? Here is another unbelievable sleight of hand by the Government. Some of the so-called ring-fenced NHS research budget will almost certainly come from the other research councils. I declare an interest as a member of the Engineering and Physical Sciences Research Council. We already fund a huge amount of healthcare research, as does the BBSRC. We will be asked increasingly to contribute substantially, at the risk of other research. We will be heavily pressured on our own so-called ring-fenced budgets. Meanwhile, regarding NHS R&D carried out by the NIHR, if we are talking about assessing outcomes, how is its performance to be evaluated? That will certainly not, it appears, be anything like as rigorous as the superb work of international quality, funded by the research councils, in our top research universities. Here, surely, is a case for government scrutiny.
Front-line care is already threatened. The dulcet tones of the White Paper with its emphasis on patient choice and outcomes are a smokescreen. Of course patients would like choice, whatever that means, but what they really want is competent, efficient medical care. I recently went to a maternity ward in one of the most famous maternity hospitals in the country to visit a relative of mine in her 20s, an NHS patient, who had recently given birth to a premature baby at 35 weeks. Her GP had given her the choice of three different hospitals and she had chosen this hospital. She was four days post-delivery and she had not seen a doctor. Her blood pressure had been 200 millimetres of mercury—a situation in which she might even have had a stroke or a seizure—but she said that she had not been seen by a doctor. She was sitting there trembling with worry. She was scared stiff. What she wanted was a doctor to listen to her and to talk to. Even though it is some time since I left the health service or have done any medical practice, I felt obliged to examine her. I went to see the nursing staff and asked whether I could speak to the house surgeons. None was available, so I asked to speak to the registrar. They did not know the name of the registrar. I had to phone the central switchboard to find out who the on-call registrar for obstetrics and gynaecology was. It was only when I left the hospital that there was suddenly an outpouring of care and three doctors visited my relative in about five minutes.
What about outcomes? Outcomes depend so much on social circumstances. Equity and Excellence: Liberating the NHS mentions cancer, stroke, asthma and so on, but the outcomes of treatment depend on the circumstances of the patient. What we learn more and more, certainly with epigenetics, is that what happens to us in early age also plays a part. What happens in a child aged two or three can have far-reaching effects on whether that child is more prone to diseases such as stroke in 60 years’ time. How do you measure those kinds of outcomes with the possibility that this White Paper offers?
Finally, to leave the—
My noble friend Lady Thornton and I have agreed to split our time, which is why I went on for the extra time. I shall finish with one sentence. If we really want to improve the health service, we should make certain that doctors have enough time to listen to patients and that nurses are not involved with so much paperwork that they cannot speak to patients, we need to improve training by better investment, we need to renegotiate the EU working time directive and we need to make certain that hospital doctors work in teams so that there is proper continuity of patient care.
My Lords, I declare an interest as a recently retired consultant psychiatrist who spent his life working in the NHS. I am married to a consultant pathologist in the NHS. My brother is a consultant in the NHS, as is my sister-in-law. My brother-in-law is a general practitioner in the NHS. I therefore speak not from the vantage point of academia or any glamorous speciality in central London but from that of psychiatry and general practice in the regions. From my perspective, the NHS is broken and needs fixing.
What are the problems that affected me during my work? Increasingly over the past 15 or 20 years, decisions were being made by a larger and larger bevy of managers and administrators at every level and increasingly decisions were being made, quite naturally, more for the benefit of the management process than for that of the clinical process. As a clinician, you could go to meetings—if you could get to them and if you were invited, and increasingly you were not—and find yourself being berated because your clinics were getting larger because you were going to the meetings, or you could not go to the meetings and the decisions would therefore be made in your absence and without any attention being paid to them. The increasing focus on managerialism over the period of the previous Government meant that clinicians were increasingly ignored. My generation thought increasingly of retiring from the NHS because they felt frustrated, not by terms and conditions of service, which improved, but by diminishing morale, as what they really wanted was the freedom to make clinical decisions.
Decisions were increasingly centralised. Targets and decisions were made in Whitehall and, with the best will in the world, what looks to be the right thing from a Whitehall perspective does not feel like the right thing when you are operating at another level. It is quite true that devolution has helped. For some time, we have had four national health services in the United Kingdom, which has certainly improved things, but the possibility for that improvement through devolution in Scotland, Wales and Northern Ireland happening in England is minimal because of the sheer size of the country. If the benefits of devolution in Scotland, Northern Ireland and Wales were to be achieved in England, it would require further devolution to local government level. Here, there is evidence of the possibility of benefit.
In Northern Ireland, because of devolution, we had proper, full integration of health and social care, which meant that it was possible for me to co-operate with social workers, that in-patient was not divorced from out-patient, that hospital care and community care were seamless and that the hospital did not soak in all the money and resources from the community whenever there were inevitable pressures. There are benefits to be had, but England needs to learn the benefits that Scotland and Northern Ireland, in particular, and, to some extent, Wales have already achieved.
The most important thing was the recognition of the importance of engaged and informed patients. Why? It does not matter how clever a doctor is, even if he can afford to make the right prescription; if the patient does not comply with the treatment, it does not improve the situation and we know that, when the research is done, patient compliance is massively lower than most doctors think. However, it goes wider than that. In my own work, it is quite clear that the fundamental difference is not the prescription of medication but the change in the culture and lifestyle of the patient. That happens only when you have a fully engaged patient—an active citizen—who is taking responsibility. Those are the principles that I see reflected in the Government’s policy and that is why I am so enthusiastic about it as a doctor.
My Lords, in the few minutes that I have, I want to speak on patient safety. I know that all patients, wherever they are treated or looked after, desire safe, good-quality care. Patients and health professionals should come together to achieve good clinical outcomes. There should be co-operation and good communication between all professionals so that patients receive what they need.
I am president of the Spinal Injuries Association and a member of the Patients Association. We have been horrified by the appalling standard of care that left Jamie Merrett, a high lesion tetraplegic who was living at home using a ventilator, severely brain-damaged when an inadequately trained agency nurse turned it off. Jamie, an intelligent man, felt that his care was often inadequate, so he had a camera and video equipment installed in his bedroom to try to safeguard himself in his vulnerable position. I have spoken to his sister and next-of-kin, Karen Reynolds, who told me that they had contacted the PCT several times to alert it to the inadequate care.
In this tragic case, there seem to be unanswered questions. Will the Minister look into this case? Does the Filipina nurse who turned off the respirator and did not know how to resuscitate Jamie have a PIN? Had her qualifications been checked? Was she qualified to work in this country and on a ventilated patient? Jamie and his sister have been let down by many people who had responsibility for his case in Wiltshire. People living with ventilators need to trust those who have responsibility for their care. This case, which has been highlighted in the press, especially by the BBC in “Inside Out West”, might otherwise have been covered up. Many people living with such equipment may also be fearful of this dangerous situation, which must be rectified. When does the Department of Health expect the National Leadership Council to respond to proposals to improve the training quality of NHS managers? Does the Minister agree that healthcare assistants should be registered?
More seriously disabled people are now living in the community. At the moment, it seems that anyone who cannot get a job goes into caring. I know that the Royal College of Nursing is concerned about this. Vulnerable patients need protection. Not only do we want honest, well trained nurses who understand how to use the necessary equipment, but there need to be well trained, honest care assistants who are registered. The Minister has responsibility for primary healthcare. I hope that he will not let down these vulnerable patients and their families, who need a safe NHS—safer than it is now.
My Lords, unlike many of the contributors to this debate, I speak only as a lay man, but a lay man who is interested in the future of the NHS. I welcome the general thrust as set out in the Government’s White Paper. All I ask is that the revolutionary changes that are being made are made with particular care and sensitivity. I have seen a number of changes from the outside over the years and I know that, whatever happens, for those directly involved it is a period of great upheaval, anxiety, uncertainty and worries about how it will all shake down. I hope that this will be done sensitively, and that after that there will be a period of real stability. Thereafter, if changes need to be made, I hope that they are made on a steady basis so that we have evolution, not revolution.
I particularly welcome the idea of the patient being at the heart of the NHS. When I was young and naive, I would have assumed that that was bound to be the case. Experience has taught me, however, that that is not always the case—one can get very lost in systems, management and all the rest of it—so I am glad to see this brought forward. I have a tiny niggle about the expression “patient-led”. It could be considered ambiguous, and I would rather have the term “patient-centred”. As long as we get the actual work done so that it is patient-centred, though, the current expression is fine.
There are difficulties for patients. I shall use one small illustration from an acquaintance of mine who has a rather rare illness that has a number of appalling side effects, so that effectively she is suffering from a number of illnesses at the same time. That necessitates not one consultant being involved in her care but several. There came a crisis point when there were directly conflicting pieces of advice from two consultants. What were the unfortunate patient and her husband to do? One could argue that it should be the GP bringing all the threads together, but I suggest that, with a rare illness involving consultants, the GP is actually in no position to make judgements or insist on what should be done. I hope that when one is looking at the running of hospitals, there will always be the idea that a very senior consultant, perhaps even nearing retirement, could bring the various consultants together and, together with the patient, make sensible decisions.
I am of course delighted to see the end of targets, which so distorted clinical management and had an appalling effect. I hope that I can have the encouragement of the Minister to say that they will go completely. However, I see a case for them if they are done at very local level by the people intimately involved—say, a GP’s practice or an individual hospital—where they can see what they need to do and can set their own local target. That is the only place where I could see some sort of role for targets, and they could be useful.
When we come to outcomes—in my terrible lay man’s language, that means that you either kill the patient, cure the patient or something in between—I hope that the Government will be careful not to fall into the trap of the targets and have outcome measurements that do not actually fit the bill. It is an extraordinarily difficult thing to do and I hope that great care will be taken. That said, though, I welcome the White Paper and the Government’s intentions.
My Lords, I have no problem in endorsing the principles described in the White Paper—patients at the centre, devolving responsibility and so on—but they sound rather familiar. There seems to be a close resemblance to the aspirations that came out of the many NHS White Papers and Bills that we have seen in this House over the past few years. I have watched these come and go, as someone who worked for many years as a consultant in the NHS and as a past president of the Royal College of Physicians. The question, as always, is how to implement these fine ideas.
I shall focus on the proposal to change the PCTs to GP consortia. If this sounds familiar, just remember GP fund-holding; the new proposals sound only subtly different. So, if fund-holding and PCTs failed, why should GP consortia work? Success always depended on the enthusiasm and skills of GPs, and unfortunately these are not evenly spread. GP commissioners have to assimilate large amounts of data about their patient populations and their diseases, know about financial and risk management and have statistical skills and an ability to develop contracts—and none of that can be done between seeing patients or after the evening surgery. Little wonder that few have expressed any enthusiasm to take on these responsibilities in the past, nor have they now. GPs will certainly need help. That can come only from re-employing either experienced staff made redundant when the PCTs are disbanded or those from the private sector, who are unlikely to be in the game for charity.
We know that PCTs are not uniformly good at their job; some are excellent while others are less so. The reason is that there just are not enough of the skills needed to go around all 160 of them. If we have a similar, or greater, number of GP commissioners, we will run into the same problems. All this points to a need to keep the numbers small—I reckon no more than 20 or 30. That would allow a small cohort of committed GPs to work with a few experienced managers. The projected cuts in management of 45 per cent just endorse the need to keep the numbers small. What ideas do the Government have about the number of GP commissioners that they envisage?
The numbers are not the only problem, though. The system seems designed to divide primary and secondary care still further. We can talk glibly of “seamless care” between hospital and community, but there are many ways in which these need to be co-ordinated. Indeed, any complicated disease—one has to think only of geriatrics, mental illness, stroke and so on—requires hospital specialists and GPs to work closely together in designing packages of care. It is vital for commissioning bodies to have the direct involvement of specialists in developing contracts for what should be integrated care. What efforts will be made to ensure this vital close collaboration in a competitive climate?
Then there is the question of commissioning for education and training and for research. I have many concerns that, as these are devolved to the local level, they will be lost in the hurly-burly of commissioning for efficient and economical care in the face of savings targets of £20 billion. There is little evidence that GPs will pay more than lip service to the aspiration in the White Paper to “embed research” in the NHS. A recent survey showed that GPs were antipathetic to their being involved in research using patient data, and were unhappy with the extra work involved in obtaining consent from their patients. When key commissioners are so uninterested, it does not bode well for the future of research or teaching in the NHS.
I do not want to say much about the involvement of the private sector in commissioning, save that it is quite unclear what incentives they will have to encourage education, training and research. How will the Government ensure that they will not be damaged in the change to the new arrangements?
My Lords, I, too, thank the noble Lord for introducing this important debate, especially as it emphasises the importance of the individual taking charge of his or her own health. This is crucial, as the present obesity epidemic will kill millions, and half the population will be obese within 20 years.
There has been a great emphasis on exercise as the answer to obesity and, indeed, exercise is very important in maintaining our health. Muscular activity is good for the muscles themselves, good for our bones and good for the heart. It promotes optimal levels of cholesterol, enhances morale and gives us a sense of proportion. Of the calories we consume, 75 per cent are burnt up by the organs of the body such as heart, liver, kidneys, brain, pancreas and so on, but we have no control over that. We can control muscular activity but, unfortunately, muscular activity consumes only 25 per cent of the calories we eat and drink. If we wish to take off a pound of weight through exercise, we have to run a mile. The problem for obese people is that it is difficult for them to exercise. The answer to the obesity epidemic lies in diet. What and how much we eat have a far greater impact than exercise.
It has been assumed that inactivity leads to obesity but it is quite likely that it is the obesity that results in inactivity. Professor Terence Wilkin has been following the same cohort of children over 11 years. He found that, at least in children, inactivity does not lead to fatness, while fatness does lead to inactivity. It is very unfortunate that politicians have been misled by NICE into believing that our weight is determined by a balance between exercise and what we eat. It is simply not true. It gives the false impression that exercise and what we eat are equal contributors to body weight, whereas the evidence proves that what we eat has a far greater influence on our weight than exercise.
Clearly, there are many contributory factors leading to obesity, such as genetic background, thyroid failure, big bones, fluid retention, psychological factors, sexual abuse and so on. However, at the end of the day we are what we eat. I was brought up in the war when food rationing meant there were no obese people apart from those on the black market. At the beginning of the war, one third of the people were either underfed or fed on the wrong food. Rationing cured that almost overnight. It was the greatest and most successful public health experiment of all time.
What can the Government do to reduce the death rates from obesity and protect the NHS from being overwhelmed by the increasing deluge of patients with diseases resulting from obesity? The first thing that would help would be for the Government to tell their members to start giving a clear signal to the public that the real answer to obesity is to reduce the quantity of food they eat to healthy levels. The second thing is to point out that, although exercise is good for the heart and ideal cholesterol levels, it plays a small part—25 per cent—in dealing with obesity. This would reassure the army of obese people that they can take control of the situation by eating less, and then beginning to take reasonable exercise when their bodies have reached a manageable size. Thirdly, the Government could encourage the food industry to increase traffic light indicators on food it sells in order to reduce the amount of junk food. The fourth thing is a much greater drive in schools, ensuring that children and young people understand that eating sensibly will stop them dying at an early age.
The government action against smoking was very successful, but the death rate from the obesity epidemic will prove much greater than that from smoking. Time is running out. Will the Government act now?
My Lords, I rise with some trepidation, following that. I congratulate the noble Lord opposite on this debate. I declare an interest. I have only just become a member of the board of County Durham and Darlington Foundation Trust as a non-executive. I claim no knowledge or benefit from that for this debate, however.
I have been delighted to see that the Government—and the Conservative Party, before the election—have really discovered how much the National Health Service is valued by the British people. We have that to thank for their commitment to the National Health Service during the election, and to ring-fencing the money for it. However, as we are now discovering, that ring-fencing has lots of problems within it. The rounding-up of figures, which all Governments do, means that the annual increase will be 0.1 per cent. In fact, it is a little less than that, but that is the rounded-up figure. We all know that that will give the National Health Service incredible challenges. I want to ask the Minister some questions arising from that settlement and the ideas in the White Paper.
The financial challenge is significant. What does the Minister think the number of redundancies within the National Health Service will be this year and next? How will those redundancies be funded? There are rumours that the funding for redundancies will come from some of the money put into the service to control demand—for example, in accident and emergency, by encouraging more people to be referred, and refer themselves, to urgent care centres. However, there are also rumours that some funding may come from budgets that are about trying to get healthcare to the most vulnerable, such as the homeless, who are frequently not on a GP’s list.
I know that many Members welcome the abolition of targets. I am amused to hear them now called “objectives”, but that is another matter; I am determined not to be cynical. When I was a directly elected Member of Parliament the main concern expressed to me by constituents about the National Health Service was, “I have been to see the doctor and been told that I can have the operation in about 18 months to two years. I could go next week if I was private”, with all the horror, anger and shame of that. That has not happened over the past five years. How many NHS patients does the Minister think will be waiting six months for orthopaedic surgery in February 2012? Does he think it will be 10, 100 or 1,000? I know that Ministers think carefully before they make any decisions. The decision to abolish the targets means that the Government must have estimated what effect that will have. I want them to share that thinking with us.
Inevitably, the change to the regime that the Minister envisages in the White Paper clearly means that some NHS hospitals will fail. How many does the Minister think will have failed by April 2013?
Finally, on parliamentary accountability, the Government are going to create the largest quango we have known in this country. That will take it outside direct questioning by Parliament. How is Parliament going to hold to account the decisions and actions of the NHS when, in fact, the money will be spent by the largest quango, the commissioning board? Who will appoint the chair? Can the Minister assure us, now that the appointments commission is to be abolished, that it will be an impartial appointment? Will it be done before the appointments commission is abolished?
My Lords, I, too, will focus on what we mean by patient-led healthcare, which others have mentioned before me. In November 2005 a best-practice document called Now I Feel Tall: What a Patient-Led NHS Feels Like was published. It said:
“I strongly encourage all NHS organisations to take a close look at how they deliver their services and to ask their patients if their emotional needs are being met as well as their physical ones”.
It goes through what patients should look for. This includes,
“getting good treatment in a comfortable, caring and safe environment, delivered in a calm and reassuring way … having information to make choices, to feel confident and feel in control … being talked to and listened to as an equal; and … being treated with honesty, respect and dignity”.
The core and developmental standards for the NHS were set out in seven domains, the fourth of which is patient focus. It says:
“Health care is provided in partnership with patients, their carers and relatives, respecting their diverse needs, preferences and choices, and in partnership with other organisations … whose services impact on patient well-being”.
It therefore requires,
“healthcare organisations to have systems in place to make sure that staff treat patients, their relatives and carers with dignity and respect”.
Healthcare organisations must monitor their performance with regard to treating patients and carers with dignity and respect. The evidence has always been clear that if the NHS listens to what patients are saying, it can result in new ideas, better value for money and better care. How do you measure targets in an area such as patients being treated with dignity and respect, and being listened to, when trusts will point to the often relatively low number of complaints as a measure?
There have been numerous inquiries and other pieces of legislation setting out how to empower both individuals and communities in shaping health and social care services. Since community health councils were abolished in 2003—a great mistake in my view, and I declare an interest as I previously worked as the chief officer of a community health council—we have seen numerous attempts to make the NHS more meaningful and accountable. The establishment of local government overview and scrutiny committees with new duties went a long way to bringing accountability to healthcare services and in my view, as a previous chair of an overview and scrutiny committee, shone a welcome light into areas of healthcare services that had not previously been scrutinised. It brought about the need for greater partnership and collaborative working between local government and health. However, again, it relied on local PCTs and other healthcare trusts welcoming and being open to this scrutiny and accountability.
I welcome the Government’s plans to create local government health and well-being boards, but there have been problems on the ground in the way local government and the NHS have to work to bring about greater public and patient involvement in the NHS. In my own area, the local PCT last year took the decision to close a much loved and important health centre, in the most deprived part of the borough—the Finsbury Health Centre. The health and well-being committee scrutinised this decision in some detail and at considerable length, hearing evidence from patients, the public and clinicians. Eventually, after careful consideration, it presented its findings to the PCT, which fairly quickly rejected them. It found itself at loggerheads with the whole health and well-being committee, the council and the overview and scrutiny committee. It did not allow, for example, the chair of the committee to address or present its findings to the PCT board. As a result, the relationship between elected councillors and an unelected board of rather anonymous people, led by the chief executive, who had no accountability to the public, suffered. So, too, did local community confidence in the PCT.
People increasingly want to be able to exercise choice and control over their care. To do this it is clear that people must have the right to reliable information to help them make choices. Things have improved dramatically in some areas over recent years but what has not improved is the consistency across the NHS. My family’s experience of the NHS has been patchy. Three years ago my father spent seven weeks in hospital, suffering from terminal cancer. I saw at first hand how this 87 year-old man was gradually stripped of his dignity. While some of the nursing staff were enormously professional and provided excellent healthcare, others did not. He was not treated with the respect and dignity he should have expected. He was left in pain, with bed sores, little personal care, and alone on the floor after a fall in his room. This was a proud man, who would not leave the house without a shirt and tie, reduced to tears of humiliation just days before he sadly died. After my father’s death, I decided to complain formally about the senior member of nursing staff who had been so unprofessional to my father and my family. I was perhaps not surprised to learn that there had been a number of complaints about this individual, but none had been taken very far, due to the sheer difficulty, time and bureaucracy involved. This is not an easy time for families and carers.
I welcome the fact that patients will have more choice in terms of their GP. I hope the reforms will underpin not only greater choice but more consistency across healthcare services, so that people like my father have a better experience of the NHS.
I remind noble Lords that this is a time-limited debate. There is another important debate following ours. We need to give noble Lords in that debate the courtesy of being able to start and finish on time. I remind people that when the clock reaches four minutes, noble Lords have spoken for four minutes. There is also somebody who wants to speak in the gap.
My Lords, I will use my four-minute slot to talk about the role of health professionals—one of the aspects mentioned in the noble Lord’s Motion. I am a former cog in the NHS machine, so I have some knowledge of working there. When my noble friend Lord Darzi spoke of increasing the involvement of clinicians in NHS decision-making about three years ago, he was thinking of drawing on their experience of the realities of front-line medicine and surgery. Now what is proposed is the greater involvement, especially of GPs, in the complex process of commissioning care. This requires many skills which are outside the training and interest of the majority of practising doctors. It is true that many PCTs are not up to speed and we have heard that some of them are remote.
The final report of the Health Committee of the previous Government said that PCTs,
“employ large numbers of staff, but”,
too many are not of the required calibre. It went on to say that PCTs need to become, “better at collecting data”—for example, on the needs of their population—and at analysing them. That is not a very flattering remark, but are these weaknesses enough to justify closing down all PCTs and replacing them with GP-led consortia, with all the upheaval and chaos—not to mention expense—which is caused by such a major reorganisation? I think not, because the skills in which the Select Committee found PCTs to be weak are not skills possessed by the average practising GP, whose training lies in assessing and treating the health problems of individual patients and families.
Of course, some have developed a wider outlook and are interested in public health and preventive medicine, and some have considerable entrepreneurial skills, as the department knows well, but these are a minority. The expertise needed properly to commission healthcare for a given area includes an ability to assess the health needs of whole populations, not simply those on GP practice lists, as well as managerial and planning skills—the very skills which the Select Committee found wanting in many PCTs. GP consortia are likely to have the same or greater shortcomings, even if they re-employ all the most expert staff now working for PCTs because of the disruption of working relationships which will follow the abolition of the PCTs. Also, staff with these skills are those whom the newly empowered directors of public health—which, with provisos, I greatly welcome—working with local authorities, will require to assist them in their enhanced new role in local government, so there will be competition for staff with the appropriate training and expertise.
As the noble Lord, Lord Hunt, said, independent consultants and healthcare firms are waiting to step in to fill the breach—at a price, of course. Sometimes one wonders whether this was the main purpose of the whole exercise. Perhaps it is too much to hope that the Government might think again considering the very hostile reception that this proposal has received from nearly all health professionals and health think tanks, including the King’s Fund. In the final seconds of my speech, may I ask the noble Earl whether he can assure us that the newly empowered directors of public health, who will be working with local councils, will be fully funded, that this funding will be protected and that they will also have a statutory role in their work with local government?
My Lords, I too, thank the noble Lord, Lord Hunt of Wirral, for giving us the opportunity to debate this subject. The contributors to the debate will know just how important it is to everybody. I declare an interest as the chair of Barnet and Chase Farm Hospitals NHS Trust, an acute trust delivering general and highly specialised healthcare to a large area of north London.
The policies of any Government have a direct and profound effect on the quality and outcomes of patient care. For some time our trust motto has been, “Patients First and Foremost”. Our staff work towards this vision at every stage of their careers and throughout all government policies regardless of the party, or parties, in charge. That is why I have paid great attention to the Government’s policy on patient-led healthcare.
Much progress has been made on the timeliness of services within the NHS through the target-driven process initiated by the previous Administration—my Government. The present Government’s moves to dismantle this structure must not be allowed to lead to the loss of these crucial improvements, but rather build on them. However, the time may be right to move from the assessment of service quality by time, which was an imperative at the point these processes were introduced, to combine this with the more clinically sensitive indicator of outcomes. I feel that it is a pointer to the success of the previous Administration in upholding the original vision of the founders of the NHS that we are now able to consider such a transition. Within my own trust great strides have already been made in many areas, particularly with the reorganisation of the A&E services and acute medicine, leading to shorter waiting times and a better service for our patients. Future progress in these areas may be better measured by combining quality of outcome rather than timing alone, important as this has been in increasing our standards to the present levels.
In other areas such as modern cancer services, which received a massive investment under the previous Administration, the question of timeliness of care has again largely been addressed. Perhaps we should move to realising the benefits in terms of quality and outcome measures made possible by previous investment. However, I caution that we should do this without taking our eye off the ball as regards acknowledging the importance of timely action for those diagnosed with or suspected of having cancer of any kind—for those people, time is of the essence. In my trust, great changes have taken place in providing local, modern, advanced cancer services, with the use of laparoscopic and robotic techniques. It is important that this is maintained and monitored against the highest national and international standards.
Many patients served by my trust are elderly. We must recognise the demographic changes, as other noble Lords have said. The country as a whole must think about this in the design of its services. For this enlarging sector of our population, true quality of service demands not only timeliness and excellent outcome but an additional vital ingredient: local provision. Some services that my trust provides are excellent by national standards, and the outcomes are very important. We must not in any way threaten them by an ill thought-through, centralised agenda. The knock-on effect of removing these local services will, if allowed to progress, threaten to undermine excellence in other areas that they support. The White Paper says exactly the opposite of this. Localism is really important. I ask the noble Earl for that confirmation today. Localism is important: people know what is important to them locally. I am sure that the noble Earl, who is smiling at me, understands that from the recent visit that he made to my trust.
I finish by saying that the role of front-line health professionals is paramount in ensuring that the delivery of this White Paper, and more importantly of health services overall, is recognised by patients. The implementation of government policy is a weight that they carry. It must not become such that it interferes with the delivery of services. Make no mistake: we are being watched by everybody. As a trust, we think that it is very important that we are able to step up to the plate, as the saying goes.
My Lords, the coalition Government’s strategy for the NHS is clear and very welcome. The first stage is the White Paper, consultation on which has just been completed. The responses were of a good volume. Three objectives were outlined in the White Paper: the one that we are discussing today, creating a patient-led NHS; improving healthcare outcomes; and increasing autonomy and accountability in the NHS. We also know from the comprehensive spending review that the funding is ring-fenced and is available only for the NHS.
Frankly, I sat in blank amazement listening to the noble Lord, Lord Winston, claim that at the general election the NHS was in its healthiest state for decades. I remind him that we were left with mixed wards, which we were told 13 years ago would be got rid of. We had the chaos of out-of-hours cover. I do not need to remind the noble Baroness on the Front Bench of a number of tragic cases. We had a situation where a number of brought-in, standby, out-of-hours doctors did not even speak English. We have had questionable care on the nursing front. I support what the noble Baroness said earlier. My wife is a retired GP and is pretty objective when it comes to nursing care. I am sorry to report that nursing care at Papworth is certainly not world-class. Frankly, it is pretty poor. We have a situation where cancer drugs have not been sorted out for the past 13 years. I make a plea to my noble friend on the Front Bench. If we have £200 million of ring-fenced money for cancer drugs, although it is to be deputed to the existing regional health authorities, can we not consult with cancer charities on which drugs they think would be a primary help in that particular budget? Perhaps I do not even have to mention IT and the billions that were spent on something that has not worked. Do not tell this Government that the NHS was left in the best state ever after the past 13 years.
I look back to a time when my wife was a second-phase GP fundholder. Most GPs were in the fundholding scheme: only a hard core were not. That was successful; it worked. It is no good the noble Lord shaking his head. GPs who went into fundholding achieved very short lists for operations. The scheme worked well and I am sorry to say that it was only through prejudice that the incoming Government got rid of GP fundholding and then produced modified targets that they thought were a substitute for it. They were not.
I will finish by saying a couple of words about medicines. Traditionally, medicines in the NHS have taken up between 10 and 12 per cent of the budget. I have noticed two worrying developments. First, the standard of generic substitutes is not what it should be. We have seen the recent case of Lipitor, and a number of other cases are documented in the pharmaceutical area. Something must be done about that situation. The second is counterfeit medicines, which I do not think were a problem 13 years ago. Again, I am not blaming the outgoing Government for this but there is now a problem across Europe with counterfeit medicines, and I shall mention two statistics. First, 62 per cent of medicines bought on the internet are counterfeit or substandard and, secondly, across the whole of Europe in 2006 no less than 2.7 million fake medicines were seized. I do not wish to say any more, other than that I look forward to receiving answers to the questions that I have raised.
My Lords, until last year I was a non-executive director at a foundation trust hospital, and I am an independent assessor for clinical excellence awards at both local and national levels. Therefore, to that extent, I declare an interest.
My views are of course influenced by personal experience. I remember what the National Health Service was like before the Labour Government were elected in 1997. It was coming up for air for the second time. It was starved of resources, innovation and decent buildings. However fashionable it may be to condemn target cultures and so-called spending sprees, the Labour Government tried to catch up on a generation of neglect. Waiting lists were the scandal of the day, with demoralised and underpaid staff and a Nissen-hut building culture. Some of us will never forget that and will for ever be proud of what Labour tried to achieve. However, it was always going to take a generation to succeed and unfortunately we did not have that amount of time.
I always assumed, perhaps naively, that a coalition Government were about strategic consensus but I just wonder whether this coalition Government are not about mixed messages. They claim to support localism but set up the biggest quango in the world, doling out £80 billion. It does not get much more centralist than that. The NHS Commissioning Board will also be taking on responsibility for specialist commissioning and at least 10 other important roles. It is going to be accountable to the Secretary of State for financial stability, and, yes, it is going to be independent of the Government? If it looks like a quango and acts like a quango, surely it is a quango. In order to carry out these functions, the commissioning board will require an enormous framework to build intelligence and process information. Will it have regional offices, provided they are not called SHAs? How will this leviathan work?
Then we come to the proposals for Monitor’s new role. I have had direct experience of Monitor. I joined the board of a London hospital which had just been turned down for foundation trust status and we worked hard to achieve it the following year. Monitor’s job was, as the consultative document says, to authorise foundation trusts. If applicants for foundation trust status were not up to the stringent requirements of financial planning, sustainability, governance and leadership, they did not obtain that status. The new role envisaged for Monitor is to develop a general licence for all. Does that mean that it will lower its standards? It will certainly be a completely different body with completely different skill sets, and it will require considerably more staff to undertake the responsibilities envisaged.
Finally, within three years it is proposed to support all NHS trusts in becoming foundation trusts. It will not be an option for organisations to decide to remain as NHS trusts; they must become, or be part of, a foundation trust. Will NHS trusts still have to meet the current tough requirements in order to become FTs or will there be a lower levelling? Will those who have no hope of achieving FT status due to a long-term lack of financial viability be foisted on existing FTs, deficits and all, leading to a lowering of standards? The consultative document claims that the debate on health should no longer be about structures and processes. However, the Government’s proposals are precisely about structures and processes, and promise to be an enormous waste of badly needed resources.
My Lords, we need to retrieve the excellent reputation which Britain once had in the healthcare stakes. Not long ago, we were the envy of the world in those stakes but we are not today. Recently, I read a list of figures which showed how far we had slipped back in survival rates, standards of care and so forth. We used to be top and we are now sixth, seventh or even lower. This Government are resolved to do better and, even in the truly desperate financial state in which the previous Government left us, they are safeguarding the NHS budget. I think the figures are a little better than stated earlier by the noble Baroness.
British people love the health service and gladly support it with their taxes, but they expect to get value for their money and a good standard of healthcare when they need it. In thousands of cases, the previous Government failed them. A system grew up in which the individual patient did not matter. The most significant and important of all the new aims is that every patient will matter. You can have brilliant accountants, business experts and superb organisers running the health service, but if the welfare of patients is not a top priority, you will not have a worthwhile service.
In recent years I have raised scores of cases where patients have been treated extremely badly in hospitals and most died. Not once did any of those patients receive an apology and many of the cases I put forward were not investigated at all. The only response I ever received from hospital trusts was outrage that I should have had the barefaced cheek to criticise them at all. What on earth did mere patients matter? I am mightily relieved that this is to change. If the noble Lord, Lord Winston, thinks that there has been just one tiny case of bad treatment of patients since this Government took over, I will gladly give him my files of the other cases I have mentioned.
I am very relieved that this is to change because it seems to me that doctors and surgeons still sometimes retain their status as being one step down from the Almighty. I absolve every Member of this House from behaving anything like that, but some still do. Of course they are wonderful people and they are true saviours in many cases, but they should not treat patients as inanimate, deaf and blind objects to be discussed as if they were not there. I hope that we shall reach a situation where patients are addressed correctly and not by their Christian names, unless they have asked to be so addressed and they should not be questioned about it. I hope that they will not be put in mixed wards, unless it is an intensive care ward. I also hope that cases such as my noble friend Lady Masham brought forward will mean that we shall have switches that cannot be switched off unless there is clearly someone to turn them on again or switches that will not go off. I ask my noble friend if these vital improvements might perhaps be achieved in less than three or four years, as the report indicates. We need them so much.
My Lords, it is interesting that numerous professional societies which deal with chronic illness have concerns about potential inequalities of commissioning, the lack of involvement of specialists in commissioning and the potential fragmentation of services that an expansion of the internal market would generate. However, I have been made aware by the British Thoracic Society of its separate anxiety, which relates to the apparent lack of prioritisation for patients with long-term lung disease. The previous Government, at the instigation of the chief medical officer and the Department of Health, spent four years developing a national strategy for COPD and asthma that went out to public consultation earlier this year. The accompanying economic impact assessment made it absolutely clear that good-quality, integrated, community care for people with COPD would improve care and save about £1 billion over 10 years.
There is no mention of this in the White Paper, and there is general concern that it has been dropped on ideological grounds. The assessment of services on markers of quality is admirable where it exists, but it is likely to focus on what can be easily measured, such as cancer rates, heart disease, et cetera, not on what needs to be measured—such as the impact of chronic lung disease. I should declare that I have severe allergic brittle asthma and can get very ill within a few seconds, and that I was a member of the Select Committee considering the provision of allergy services.
The European Union, under the Belgian presidency, has adopted chronic respiratory disease as one of two priorities presented to the Council of Ministers in Brussels last week. It would be a shame if England were not to promote recommendations for improvement in costs and quality of care by integrated working. Numerous societies would like the national strategy to be implemented, and I hope that the noble Earl will be able to address that concern.
I am aware that there is a new allergy clinic in the Midlands, but there are still insufficient trained allergists for the demand throughout the country. Patients with allergic conditions are sometimes given inappropriate treatment by other, non-allergy-trained doctors. I hope that the noble Earl will also address that concern without delay.
My Lords, I want to make a few points about health and social care. How do we provide quality healthcare that meets the real needs of patients in today's world? Will the popular biomedical model of health meet all those patient needs, or does its internal logic present us with a limited view of what a human being is and provide us with an expensive approach to healthcare? Is what we say that we believe about health believable?
The GPs I work with in east London tell me that in poor communities such as Tower Hamlets, 50 per cent of the patients they see do not actually need a doctor; they need something else. What presents itself as illness may actually be more to do with a patient's isolation, the need for a friend or a job, better housing or a more creative lifestyle. In such cases, attempts to find a magic pill or potion are inappropriate and a waste of resources; GPs and patients need our help.
In this new financial environment, there is an opportunity to begin to open up a more integrated and cost-effective approach to healthcare at a national level which builds partnerships between health and social care professionals and with the voluntary and social enterprise sectors, but it will require encouragement and leadership from within government if this more integrated and cost-effective approach is to work.
GP practices are anchors in local communities that could play an important role in the development of the big society. Four years ago, I was asked to intervene by the then CEO of the local authority in St Paul's Way in Tower Hamlets, which is a single street in one of our most challenged housing estates. I am now leading the St Paul's Way transformational project, so I declare an interest in this project, but I am pleased to say that it is fast becoming a pathfinder used to illustrate the benefits of joined-up working. We are now exploring the possibility of creating a community interest company, which in time may manage the facilities along the whole street. When I first arrived on the street, I was shocked to discover that there was the possibility of developing a new £40-million school under the BSF programme, a new health centre across the road and 500 new homes. So what was wrong? None of the key players in health, housing or education were talking to each other.
The new focus on patient-led healthcare could result in new relationships between doctors and health professionals and local members of the voluntary and social sectors. This more integrated approach is important because, at present, strategy is running on departmental lines. Education is introducing free schools, health is devolving budgets to GPs and social services are extending personalisation budgets. Society does not operate along departmental budgets. Go to any town or city district and ask the police for the top 100 families that they routinely deal with for anti-social behaviour. Ask the GPs who are their most demanding patients; ask the housing office and the courts. The same names will keep appearing. Despite decades of rhetoric, the same tragic newspaper headlines will keep appearing—baby Peter being one horrifying example.
Unlike the initiatives of the previous Government where the state was encouraged to be joined up, my colleagues and I would suggest that the state will never be joined up and that the answer is to let communities and local organisations, such as GP practices, join up on local streets to deliver joined-up services. I am encouraged that this is the direction that the Government seem to be taking us. We must take the opportunities that this presents. I suggest that in this financially strapped environment there is a new opportunity to turn this old health logic on its head. But the Minister will ask how we are going to do this and how we will create the physical environments on the ground within which this can take place.
One answer is already there; namely, LIFT, the Local Improvement Finance Trust. We could do a great deal with this, but there is not time to go into the detail. I leave the Minister with one question: will he tell the House how he proposes to encourage GPs to take up the opportunities presented by the transfer of funding to GP practices? What is the Government’s plan for general practice to play in the creation of the big society?
My Lords, I will concentrate my remarks on public health, particularly sexual health, on which I have spoken so often in this Chamber. It is clear that the White Paper does not understand current provision for sexual health, to which I shall return in a moment. First, I should declare an interest as chair—I still am for another few weeks—of the Independent Advisory Group on Sexual Health and HIV. I am encouraged that sexual health is still on the agenda, with a new committee being established. I hope that the committee will have the capacity to ensure that sexual health and HIV does not go back to the days of being the Cinderella service that it was under the last Conservative Government.
The introduction of a public health service, incorporating all aspects of sexual health, could provide the opportunity to commission improved and holistic sexual health and HIV services, and to join those up with other allied public health services. But, as my noble friend said, local government will be taking on this responsibility with no experience in the field whatever. There has to be clarity as to who will be responsible for commissioning sexual health and HIV services.
I am not in any way opposing the concept of patient choice and I am pleased that it will cover aspects of long-term care. But there is a uniqueness about sexual health, for health promotion and healthcare have been and should continue to be clearly linked. To maintain that link, overlapping frameworks for health, public health and social care are essential, which has been achieved in the sexual health field by community clinics. Where do community clinics for STIs and contraception fit into the new structure, because there is no mention of them? Has an impact assessment been undertaken to identify their value? They have provided a model of patient choice from a range of providers. That model is now threatened by the shift to GP commissioning. Considering that few GPs want to take on this work, I have to ask whether the community clinics will continue and whether the GP consortium will commission them to do the work.
A matter of great concern is education and training, which will now be the responsibility of providers. An enormous knowledge gap has to be filled by GPs, nurses, and local authority staff. Who will determine the level of training required? Who will pay for it? Who will determine the level of standardisation and accreditation that is required? A lack of experience among GPs and local government means that it is unlikely that they will be able to commission effectively.
Many patients want support and advice to make sense of their options. It is therefore essential that all patients have confidence and trust in the choices being offered, which means a workforce that is properly trained and skilled. With the abolition of the PCTs and SHAs, this will be further exacerbated because many staff are already leaving the service. That loss of trained personnel will seriously affect the whole question of how much training will be needed. Patient choice and quality of service are already being diminished by closures of services in public health and in some hospitals. For instance, one consultation document produced by the Government talks about choice for those who are dying. At the same time, I am aware of at least one special NHS unit to ease dying for the patient and their families that has been closed down. Those people are not being given a choice and their objections are not being listened to. There are cuts in the provision of chlamydia screening, with clinics closing and reductions in contraceptive services. These front-line services are easy options for cuts which will deny the patient not only choice but access to services.
Many issues arising from the White Paper still have to be resolved, but how do we convert rhetoric into reality? At the moment we have fine words but we need much more than that: we need absolute detail.
My involvement with the National Health Service is that five years before I joined your Lordships’ House I was the chairman of a local family health service authority in Barnet. I was responsible there for overseeing what went on in the general practices, working with National Health Service doctors and dentists and with pharmacies. We initiated a new scheme in the pharmacies called High Street Health. This scheme spread around the country, but was started in Barnet.
I was also for some four years the chairman of the national league of hospital and community friends. The branches of hospital friends consist of those tireless volunteers who work in our National Health Service hospitals, providing all kinds of patient services and comfort, running news stands, and raising money for patient amenities and even sometimes for much needed equipment. In other words, they were acting as the big society more than 60 years ago, although we now hear so much about it being a new idea.
From my contact with the dedicated workers in the friends organisations and in my work in a local health authority, I have knowledge of what patients and users want. Of course, I do not have medical knowledge; mine comes from a completely different angle. The White Paper, which I think is an excellent consultation, talks a lot about outcomes but I can tell the Government what outcomes patients want. First, they want to get better; as part of the process of getting better, they want a GP who knows them personally, with the kind of friendship that I and my family have been lucky enough to have with our local doctor. If they go into hospital, they want it to be clean and germ free so that they are not in danger of coming out in a worse condition than when they went in. As has been mentioned by others, they want an end, once and for all—and without delay—to the scandal of mixed wards. Numerous Health Secretaries on both sides—I am not accusing any one Government of this—have promised it but it has not been delivered. There is no excuse for this third-world arrangement. It is not appropriate; it is an inexcusable penny-saving matter.
Another outcome that patients want is that the National Health Service will provide medication when they need it. They do not want to find that treatments are available in some parts of the UK but not in other parts, or that they are denied to United Kingdom residents but are freely available on the continent.
The training of future doctors is a matter of equal concern. Without being in any way chauvinistic, the public want fluent English-speaking doctors. The working time directive, which limits the hours that poor young trainee doctors are able to work, is having an adverse effect on their ability to gain the skills they need to become specialists themselves.
I regret to say that the National Health Service has been a political football between the parties for far too long. It should stop. No party has done exactly as much as it should. Let us hope that this consultation will provide what is needed for this, as my noble friend said, patient-centred and led health service.
My Lords, the noble Lord, Lord Hunt, and I last had a brief encounter about 25 years ago when he chaired the inner-city partnership in Newcastle and I was the leader of the city council. I cannot say that that brief encounter leads me to the noble Lord’s Motion in a blithe spirit, but I shall begin as I do not mean to go on by welcoming at least some of the proposals in the White Paper, particularly the return of public health to local government, whence it was removed by Sir Keith Joseph’s reorganisation in 1973, and the conferment on local councils of leadership in health improvement. Both will be good examples of integrating services rather than fragmenting them, which so many of the other proposals in the White Paper will certainly do.
The House will of course welcome the emphasis on patients and clinicians expressed in the mantra that the noble Lord reminded us of: “No decisions about me without me”. It is a pity that that mantra was not applied to the development of the policy that has produced the massive changes that we are debating today.
The White Paper and the Motion seem to imply that, until now, patients and patient care have not been central to policy, as if the record investment in hospitals, clinicians and nurses and the massive reductions in waiting lists were for the benefit of bureaucrats rather than patients. My own personal experience certainly refutes that, unlike the unfortunate experience of the noble Baroness opposite, who told us about her father. Eight weeks ago tomorrow, my wife died, two years after being diagnosed with cancer. She was a health visitor and nurse, but worked with GPs on training. We had nothing but praise and gratitude for the care that she received in a state-of-the-art cancer unit opened just 18 months ago. She was the daughter and sister of doctors and she would want me to say that she entertained grave doubts as to the proposal to go wholesale into GP commissioning, doubts that are shared by the BMA and many others.
It seems extraordinary that GPs are to be conscripted into consortia, whether they like it or not, with no evidence of their capacity to commission and no assurance of coterminosity with the local authority services with which they must surely connect. Perhaps the Minister will indicate how many GP consortia we are to expect—we have heard figures varying from 630 to 80—and how the consortia might be expected to work with appropriate local authorities. In any event, there is a significant shift to nationalising a whole range of commissioning services, including mental health, maternity, dentistry, ophthalmology and pharmacy—so Barnet would not have been able to do its own pharmacy commissioning under these schemes—which will fragment the key relationship with local councils. Commissioning should be local, involve councils and be piloted.
In addition, it is clear that accountability will be weakened as local government scrutiny powers are watered down. A national board will oversee GPs; health and well-being boards with little local government representation will, in effect, scrutinise themselves; an increasing number of hospitals are to be dragooned into foundation status; and, with the concept of “any willing provider”, as the BMA states, there is a significant risk of two-tier services developing, threatening value for money in the NHS.
Much of the White Paper and the debate today is based on a presumed thirsting for choice, which in the BMA’s view—I think that it is shared by many other observers—does not really exist in the form that is imagined. The BMA rightly suggests that, most of all, patients want a high-quality provider close to where they live and to receive timely, competent diagnosis and treatment. The White Paper blurs the distinction between personalisation, which is essential, and choice of provider, which is not. The BMA recognises the need for some proportionate targets.
Support for the Secretary of State seems to be underwhelming from most professional bodies and patient organisations. We are in for a massive and expensive reorganisation, which has been determined with consultation restricted to the detailed application and not the principles. There is no sign here of any clinical trials. The Secretary of State is guilty not merely of a rush to judgment but a rush to misjudgment, with potentially serious consequences to the NHS and the people whom it serves.
My Lords, with so little time for niceties or an introduction, I shall concentrate my remarks on the management of those with muscular dystrophy and therefore declare my usual interest. I know that my noble friend the Minister has in the past attended the all-party group here in the House, which has endeared him to all those working in this particular field. I wonder whether he would be prepared to meet the group again soon in his new role to discuss some of the issues that I shall mention today and some which there is no time to mention.
Some 60,000 children and adults in England are affected by one of more than 60 different types of muscular dystrophy. These are rare or very rare conditions that weaken and waste muscles. They can cause lifelong disability and, in some cases, premature death. There are currently no cures or treatment and, without multidisciplinary care, most patients and their families experience a further reduction in the quality of life and, for some conditions, shortened life expectancy.
The Muscular Dystrophy Campaign, in its responses to the White Paper consultations, has welcomed the proposed NHS commissioning board for specialised services and believes it to be a necessary step towards a national neuromuscular service for those with these neglected conditions. We urge the Government to make sure that the board is well enough resourced to ensure that all who need care can access it wherever they live.
As for GP commissioning, it is clear that GPs simply do not have the knowledge, experience or patient numbers to commission services for these extremely complex and rare multisystem disorders, some of which affect just a handful of patients in the country. In addition, these are costly low-volume services, so regional commissioning is essential to share the cost among a larger population base. Currently, many people living with these conditions are denied both essential and specialised care, such as respiratory care, and non-specialised care, such as physiotherapy or hydrotherapy. It all depends where they live. The all-party group revealed in the Walton report published two years ago that this postcode lottery has had devastating consequences. Young men with Duchenne MD die on average 10 years earlier in some parts of the country than in others simply due to a lack of specialist care.
Not only is that inconsistent access to care needlessly damaging lives and families, but it is costing the health service a huge amount of unnecessary money. It is estimated that the NHS last year spent a shocking £68 million in England on unplanned emergency hospital admissions. Clinical audit data have shown that such admissions could be greatly reduced through the provision of specialist multidisciplinary care.
Spreading knowledge of the conditions that I have mentioned would be greatly enhanced if there were a new National Institute for Health and Clinical Excellence quality standard for Duchenne muscular dystrophy based on the internationally agreed standards for care published by TREAT-NMD in the Lancet Neurology, a course of action that I hope the Minister will endorse.
My Lords, I, too, thank my noble friend Lord Hunt for initiating this debate and I declare an interest as a former chairman of an independent hospital.
In the brief time available to me, I want to speak about overseas health professionals, particularly nurses practising in the United Kingdom. I hope that this matter will be covered in greater detail in a debate for which I have my name down and which is working its way up the list. As your Lordships will be aware, nurses coming from within the European Union have the right under the recognition of professional qualifications directive to practise in the United Kingdom subject only to producing evidence of technical competence obtained from their country of origin. The relevant directive specifically prohibits blanket language testing by the Nursing and Midwifery Council as a condition of registration.
The current immigration problems faced by this and previous Governments mean that, inevitably, recruitment of skilled personnel from outwith the European Union is severely restricted. Many hospitals feel the loss of top-quality Australian, New Zealand, South African and Canadian nurses. The supply of home-trained nurses barely meets demand, so inevitably many hospitals and healthcare institutes have to rely on the only other source of nurses—the European Union.
In some member states, particularly those in eastern Europe, there is a shortage of advanced clinical technology and it follows, therefore, a shortage of opportunities for their nurses to be trained in the use of advanced equipment. As for language testing, your Lordships will appreciate that there is a considerable difference between a working level of conversational English and the very much more technical language of, for example, the surgical theatre. There have, unfortunately, been cases of theatre nurses from the EU slipping through the language competency net. I know of one incident of a wrong instrument being handed to a surgeon in the course of an operation as a direct result of a language misunderstanding. I am in no doubt that this is not an isolated incident. I do not know whether the sad case related by the noble Baroness, Lady Masham, owed anything to a language misunderstanding but, on the safety issue, there is a disaster waiting to happen.
The directive is in the course of being revisited. The relevant department in Brussels has been engaged in a consultation exercise with the healthcare professions in the Union, which will, one hopes, determine how the language issue may be addressed. I am reassured that the UK’s Nursing and Midwifery Council was appointed to collate other members’ views. I have had a helpful meeting with the Minister on this matter and am grateful for his answers to my Written Questions, from which I note that the issue of language competence is currently being discussed with the European Commission, the GMC and other organisations. I suggest that for the commissioning body, which is in the early stages of gestation, there is a good alternative in the Nursing and Midwifery Council, which is up and running and perfectly placed to undertake this language supervision.
A resolution to this problem cannot come too soon. Patient safety must not be allowed to be prejudiced by the directive as it stands. I wish the Minister well in his efforts to address this urgent problem.
I am grateful to the noble Lord, Lord Hunt of Wirral, for promoting the debate and express my gratitude to the several professional organisations that have provided me with briefings. I make a contribution today simply as an NHS patient who has no private medical care or back-up whatever. I am also a former cancer patient; I hope that that continues to be so, but I have been waiting nearly three months for an appointment to deal with a spot on my hip. I finally managed to get one this week at the Chelsea and Westminster Hospital, where, within seven days, staff will do a local operation on it. They hope that it will not be the start of skin cancer.
I was spitting blood the other day when I listened to the Minister defending the Government’s position on cancer timetabling and how treatment was taking place. In my case, it had nothing whatever to do with commissioning or the hospital. The problem arose with what has been happening within my GP practice. I know that people in GP practices in many areas are under a great deal of stress and strain and I greatly sympathise with them, but it is extraordinarily difficult when so many patients cannot get through on the phone to their GPs and so cannot get an early appointment with a GP of their choice. They cannot get a meeting with their GP out of hours—it must be at the convenience of the doctors—and certainly cannot get GPs to come out at the weekend or at night. These are issues that my Government were responsible for; they tried to put them right and did not get them put right, so the new Government should be putting them right and not moving on into other areas.
As far as I can ascertain from how things are moving at the moment, there will be little change on these fronts, or indeed on many other issues that have been raised on the Government’s side of the House when there have been complaints. The White Paper and the programme in front of us will not address those problems. I speak with a degree of anger when I see that we are now moving into an entirely new arena, which was not forecast in the run-up to the general election. There was no debate on it and it was barely mentioned. It was not in the Conservative Party manifesto or the coalition agreement, which just said that nothing was going on. I am sorry that we do not have many Lib Dem contributions today because, in the past when we have had debates on the NHS, we have been chased all over the place by them. Today they are missing and they should be ashamed that they are not standing up and taking a firm stand on these issues.
I am grateful to the noble Lord for giving way, but I have to point out to him that he is incorrect on almost everything that he has said in the last few minutes about those speaking from the Lib Dem Benches, as well as about the coalition agreement and the manifestos.
I shall not go into that—I shall move on. If we are faced with this, we need greater openness and transparency and greater access to the economic factors behind it all. If I was in the private sector, all the issues that I have just complained about, with a private GP looking after me, would have been solved. I would have had access to the information and to the costs. We should move to a position where, if people are given choices, they should know what the cost is. Equally, we should be given the opportunity under the changes to know what is being paid into the GP consortia, what profits they will make and what the private sector providers will get out of it. At the moment, this area is all within the public service, but it is likely to be privatised under the coming arrangements. Those are the points that I put to the Minister—there should be greater openness on the economic side of the operation.
My Lords, I am grateful to you for allowing me to speak briefly in the gap.
Since 1948, GPs have been independent contractors. GP practices belong to the partners, who increasingly employ salaried GPs rather than taking on new partners. In the consortium, they will need to employ advisers to manage their commissioning responsibility. Therefore, if the constituent practices are offered a good deal by a private company that also, for a fee, manages the commissioning, why not agree? That private company will then effectively own the consortium, do the managed care commissioning and keep the profits for its shareholders—effectively giving control of the NHS funds to private firms, many of which may be based abroad. Will patient need or commercial profit then determine healthcare contracts with local specialists? We live a seven-day society. Without a proper, patient-centred, 24/7 service, patients’ needs will not be properly met. I suggest that GP consortia and employment terms need a radical rethink.
My Lords, the Government in their White Paper propose to establish the independent NHS commissioning board, establish new local authority health and well-being boards, develop Monitor as an economic regulator, and expect to have the new commissioning system in place by April 2013, by which time SHAs and PCTs will have been abolished. The noble Lord, Lord Hunt, is perfectly right to say that this is big.
It is a shame, therefore, that we did not have double the amount of time for this debate to enable noble Lords to develop their arguments. We still need to have those discussions about the Government’s proposed reforms. These are reforms that will turn the NHS on its head if they are carried through, and bring with them considerable risks to patient care throughout the system—in transition, and possibly in the outcomes. As Philip Stephens said in the Financial Times on Tuesday:
“NHS reform, an accident waiting to happen”.
The Minister will forgive me if I repeat the question that I have put to him on at least two other occasions: where is the evidence base for this revolution? The noble Earl has quoted to me international league tables, arguing that the NHS is not succeeding as well as the health services of other countries; but we can both play at that game. Indeed, I can quote a table which shows how well the NHS is doing and is at the top. I will make it my business to make it available to the noble Baroness, Lady Knight. Certainly, not one of the league tables suggests that the NHS is the kind of basket case of underachievement that the noble Lord, Lord Alderdice, suggested.
The question that the Minister fails to address is: where is the evidence that requires the wholesale disruption of the UK health services to deliver what may well be legitimate improvements that the noble Earl and his Government seek to make? The noble Earl’s failure to provide the evidence leads to only one conclusion: that the evidence to justify the wholesale disruption of the NHS does not exist, and that the Government have set their face against pilots which might provide us with the proof or otherwise that this proposal will work. Legislation could then follow the evaluation of those pilots. You may then add to this that the reorganisation was not proposed in either the Conservative or Liberal Democrat manifesto. The coalition agreement said exactly the opposite—that there would be no top-down disruption. We can only assume that this is driven from within the Conservative Party by an ideological commitment, presumably led by the Prime Minister—despite whatever he may have said during the general election.
I have increasingly felt over the past month that Andrew Lansley and I are reading different submissions about the White Paper. I am reading them all, and I expect that he is, too. He seems to think that they are wholly positive. Everyone agrees that the Government’s overall objectives of patient choice and clinical leadership are right—and most of the submissions state that. At that point, I can only think that Andrew Lansley stops paying attention, or stops reading. The reason I say that is because, with few exceptions, most of the submissions—from the most positive of the BMA, given that doctors have a great deal to gain from this not simply in terms of responsibility, to the most worried, including those of the Stroke Association or the British Thoracic Association—are all saying, “Whoa, slow down. Such a large upheaval and change needs to be properly piloted and evaluated”; or they are asking the type of questions that can lead you only to that conclusion. I am afraid that so far the Government have signally failed to provide answers to some very legitimate concerns.
Certainly, there has been an outpouring of consultation papers from the department, and were Andrew Lansley not in such a dangerous hurry, that would be good. There would be a reasoned and sensible debate across the piece, but the breakneck timetable of Andrew Lansley means that there has to be a question mark over how seriously the Government are taking the concerns and reservations of an increasingly loud chorus.
This puts huge responsibility on us in Parliament in both places to ensure that these voices are heard and their questions answered and that we do not allow such wholesale disruption of the UK's health services at the ideological whim of this Conservative Government. Can the Minister tell the House what is the timetable for the proposed legislation and whether there will be an opportunity for prelegislative scrutiny? That would go some way to making this process more accountable and more considered, which something of this magnitude deserves.
If only one in four doctors believe that the proposed reforms will improve the quality of the patient care and only 22 per cent of doctors believe that the NHS will be able to maintain its focus on increasing efficiency while implementing the proposed reforms—which is what the King’s Fund says—will the Government please heed the chorus which says slow down? This is £80 billion pounds of taxpayers’ money. This is too big without more thought and explanation. This needs to be properly tested and piloted. This is people's lives and well-being. Surely we all deserve time and consideration for something so big.
My Lords, this has been an extremely wide-ranging and well informed debate, and I thank my noble friend Lord Hunt of Wirral for raising these important issues and all noble Lords who have spoken very eloquently. I share the wish that we had more time to debate these matters.
Just three months ago, my right honourable friend the Secretary of State for Health published the White Paper, Equity and Excellence: Liberating the NHS. It is an ambitious plan for reform. It is focused around three key purposes, which are the three themes of today’s debate: first, to put patients first and for patients genuinely to feel that no decision is made about them without them; secondly, to concentrate not on inputs and processes but on outcomes and to build a culture of evidence and evaluation and for innovation and evidence to drive quality care; and thirdly, in aiming to deliver the best care, we must empower the people whose responsibility it is to deliver that care. We will give general practice the power to commission services on behalf of patients, combining clinical decision-making with control of resources.
The Government are determined to improve the quality of the NHS and the outcomes for patients. Our ambition is clear: it is for the health outcomes in this country to be among the best in the world. Today, the NHS has some of the best people and the best facilities in the world, and I do not in the least belittle the improvements made to the NHS by the previous Administration, but the fact of the matter is that when it comes to what is really important—to outcomes—we lag behind. I hope that all noble Lords agree that patients deserve better. The NHS can be better, and with the reforms we have set out in the White Paper, it will be better. I know that there is a wide range of opinion about the White Paper. There always is when you try to do something substantial and challenging, but the Government have been encouraged by the widespread acceptance of the vision that we have set out and the principles of our reforms.
To deliver the best care, we must empower the NHS staff whose responsibility it is to give that care. In essence, GP-led consortia, led by GPs in close partnership with other healthcare professionals, will establish the range of services and contracts needed to give their local population the high-quality services they need and the choices they want.
The success of GP commissioning decisions will be determined by the relationships that they develop with others. Local specialist community nurses will be there to help GPs design the best community services, just as hospital consultants will be essential for designing specialist pathways before, during and after a period in hospital. Local authorities will be crucial for helping to integrate health with other local public services to optimise outcomes.
GP commissioning will not turn GPs into managers but it will enhance their role as leaders. When it comes to day-to-day managerial and administrative tasks, consortia will have a separate budget with which to buy in the support that they need, be that from a local authority, a charity, an NHS provider, an independent contractor or elsewhere. I say to the noble Baroness, Lady Thornton, that, in effect, there are going to be pilots. We plan to roll out pathfinder consortia over the next few months that will indeed pave the way and learn lessons that others can follow. GP commissioning also opens up the potential for working closely with local authorities.
My Lords, under current powers introduced by the noble Baroness’s own Government, GP commissioning can take place within certain limitations, but it is possible for GPs to engage now in the kind of joint working that we envisage and indeed that her Government put in place. I see no inconsistency there, and I think that that will helpfully inform our debates on the Bill.
GP commissioning, as I said, opens up the potential for working closely with local authorities to jointly commission services, even for the pooling of budgets to tackle local priorities. For example, by working closely with the local authority and social care providers, far more can be done to help older people or those with a disability to live independently, reducing their reliance on the NHS by avoiding things such as hospital admissions.
GPs will lead but they will not be alone. The NHS commissioning board will be there to support and advise GP commissioners and to share and spread their experiences. There will be no need to reinvent the wheel hundreds of times. One thing that the commissioning board will do as little as possible, though, is tell health professionals how to do their job.
We will also give far more power to patients. Research clearly demonstrates that treatment is better and often cheaper when the patient is an active participant in their care, not simply a passive recipient. In the coming years, we will give patients real control over when, where and by whom they are treated. They will be central to all decisions about their aftercare, often—where appropriate—spending their own budget in a way that suits their needs rather than the needs of the system.
Personal choice will not be the only way that people will be able to shape their care; they will also have a say in how local services develop. Strong local democratic accountability will be an essential part of the new system. Patients will have a strong voice in local decision-making through local authorities and HealthWatch, a new patient champion. For the first time, local people will have real powers of scrutiny over local health services.
We are very good at treating ill health in this country but we are less good at preventing it. We have the highest rates of obesity in Europe, rising levels of drug and alcohol use and, despite recent falls, stubbornly high rates of smoking. As a result, nearly one-quarter of all deaths in England stem at least in part from an unhealthy lifestyle. We have to do far more to stop people from needing treatment in the first place—to keep people healthy. We need a new emphasis on public health. Later this year we will publish a second White Paper on public health. Its aim will be to transform our approach to public health, protecting the public from health emergencies such as swine flu and improving the nation’s overall health and well-being.
I turn to some of the questions that have been asked. As I said earlier, the debate has ranged far and wide, and there have been a great many questions. We are short of time and I apologise to those noble Lords to whom I shall have to write, but I shall endeavour to cover as many topics as I can.
The speech of the noble Lord, Lord Winston, was uncharacteristic of him. I am sorry that he does not buy into the vision that we have set out. I am sorry that he does not think that we published the White Paper in good faith. The noble Lord gave the House to believe that the considerable efficiencies which we have signalled to the NHS it needs to achieve over the next four years were initiated by this Government. He will, I am sure, recall that they were in fact instigated by the previous Government. They are necessary and have nothing whatever to do with the Government’s White Paper. We need to treat more patients for approximately the same money without diminishing quality. That is the challenge.
I could hardly believe what the noble Lord said about the research budget. The announcements that we have made about research, arising out of the spending review, have been widely welcomed by the research community. We were clear that we wanted to protect science and we have done so. In the current economic climate, that is exceedingly good news.
The noble Lord, Lord Turnberg, in particular, should be reassured of our commitment to the promotion and conduct of research as a core NHS role. The White Paper makes that commitment clear. It also commits the department to a culture of evaluation. The reasons are straightforward. Research provides the NHS with the new knowledge needed to improve health outcomes. Research enables the department to know whether our policies are effective, cost effective and acceptable. The Government are committed to maintaining a ring-fence on research funding and will cut the bureaucracy involved in medical research. Work is in hand to achieve that.
The noble Lord, Lord Winston, also expressed scepticism about the whole idea of measuring health outcomes. Again, I was astonished that he, of all people, should pour cold water on our wish to do so. Just because it can sometimes be difficult to measure certain outcomes in a meaningful way does not mean that you should just give up. Great care must, of course, be taken when interpreting outcome indicators. You cannot simply make black-and-white judgments. However, if we focus only on processes, we risk creating a whole system of accountability that has lost sight of the overall purpose: improving the health of patients.
The noble Baroness, Lady Wall, asked me to underline the importance of local decision-making in the NHS. I readily do so. Those in a position to know what services are required to meet the needs of their patients are those closest to those patients—not politicians in Whitehall, but local doctors in general practice, local doctors and managers in hospitals and patient groups with local knowledge. All of this is part of our vision, which we intend to give substance. I was grateful to the noble Lord, Lord Mawson, for all that he said on this.
I welcome the remarks of the noble Lord, Lord Beecham, about health and well-being boards. It is not only they that will be scrutinising their own activities. As part of the public health service, health and well-being boards will be subject to quality and outcome standards set by the Secretary of State, and will be supported in their efforts by the public health service centrally.
The noble Baroness, Lady Masham, spoke in her characteristically impassioned way about patient safety. I agree with her that patient safety is absolutely vital. It is a key domain of our proposed outcomes framework; a key part of the quality agenda. My noble friend Lady Knight will, I am sure, agree that the most important thing that we need to do is bring about an open and transparent safety culture within all NHS organisations, a culture that is open about when mistakes are made and in which the number of serious incidents falls. Most importantly, it must be an NHS that learns from its mistakes.
The noble Baroness, Lady Masham, referred to the case of the tetraplegic man in Wiltshire whose life-support machine was cut off. This is a tragic and deeply distressing case, currently being investigated by the Nursing and Midwifery Council. Under the new registration framework, introduced in April 2010 for NHS trusts, all providers of regulated activities must register with the Care Quality Commission and meet a set of 16 requirements of essential safety and quality. These include a requirement to ensure that all staff have the necessary qualifications, skills and experience, which are necessary for the work to be performed. All agency staff must meet the same professional standards as permanent staff, as set out by the independent regulator, the CQC and each local safeguarding board. The Department of Health expects all NHS trusts to ensure that they employ appropriately qualified and supervised locums and agency staff.
My noble friend Lady Miller set out her view on which outcomes patients want. Her remarks were very helpful. I am pleased that there appears to be much commonality between what she set out and what was included in our proposals for the NHS outcomes framework. At the highest level, the outcomes that we felt mattered were preventing people dying prematurely; enhancing the quality of life of patients with long-term conditions; supporting people to recover from acute episodes of ill health and following injury; ensuring people have a positive experience of care; and, finally, treating people in a safe environment and protecting them from avoidable harm. Those domains get very close to what most of us would regard as a synoptic view of what good outcomes mean.
The noble Lord, Lord Turnberg, spoke about the need to achieve integrated care across primary and secondary sectors. I agree with him. The purchaser and provider split that the White Paper refers to must not be seen as a reason or excuse for GP consortia not to seek the advice, support and collaboration of clinical expertise on the provider side to ensure that the best possible services are commissioned for patients.
The noble Lord, Lord Mawson, asked how we can ensure that GPs will work across the community and public sector generally. Health and well-being boards have a critical role to play in co-ordinating a strategic patient-centred approach at a local level. GPs, local community representatives and democratically elected councillors will be tasked with making sure that they act on behalf of their patients and communities to deliver integrated services. A board will have a formal duty to involve and consult local people.
The noble Lord, Lord Beecham, asked in particular how GP consortia will work with local authorities. We have proposed that local government should have an enhanced responsibility for promoting partnership working and integrated delivery of services across the NHS, social care, public health and other services. It will be important for GP consortia to work in partnership with local authorities—for example, contributing to joint assessments of the health and care needs of local people and neighbourhoods, and ensuring that their commissioning plans reflect these needs.
This is obviously an issue that is in the minds of those of us in the department as well as those in the health service more widely. It is difficult to give the noble Lord a clear answer at this stage. Coterminosity does help; I agree with him. However, it is too early for me to tell him exactly how consortia will be configured. We can return to that issue.
As part of the consultation exercise, we specifically asked GP practices to begin making stronger links with local authorities and to see how they can best work together. We are currently reviewing the responses that we have received on this.
My noble friends Lord Alderdice and Lady Hussein-Ece spoke well about having informed and engaged patients. This goes back to what I was talking about a moment ago—“no decision about me without me”. That principle is a critical plank of our policy. Shared decision-making means patients jointly working with clinicians to ensure better outcomes and higher satisfaction. As my noble friend Lady Fookes said, the idea is to make the NHS genuinely patient-centred.
My noble friend Lady Hussein-Ece made the vital point that our need to focus on outcomes must reach well beyond simply measuring clinical outcomes. We need to measure patient-reported outcomes as well as patient experiences. Our proposed outcomes framework, as I have just outlined, seeks to do this. However, it is not all about measurement. It is critically important that all parts of the system, whether providers or commissioners, listen to and engage with patients, patient groups and the public more widely about their concerns and ambitions. That is exactly why we have set out proposals to strengthen the patient voice in the new system. The design of HealthWatch draws on the best of previous models of patient and public engagement.
With great respect to the noble Lord, Lord Rea, I fundamentally take issue with his point that all the major health think tanks disagree with our reform proposals. Most, if not all, agree with the vision of a health service judged against outcomes with the patient at the centre of commissioning and provision. The questions they have asked—they are natural ones—are mainly around the implementation. We have consulted on the implementation and will publish our response to these consultations. I look forward to debating the details of our proposals with him and the noble Baroness, Lady Armstrong, when the Health Bill reaches the House. I say to the noble Baroness, Lady Thornton, that that is likely to be in the spring of next year, although I hope that she will not hold me to a precise date.
The noble Lord, Lord Rea, asked us to rethink the whole idea of GP commissioning. I say to him that reform is not an option but a necessity if we are to sustain and improve our NHS. The fundamental problem is that PCT commissioning is remote from patients and does not have sufficient involvement of GPs and clinicians, who are those closest to patients and whose referrals and decisions incur the expenditure of the NHS budget. They are the people who can do much to improve the quality of care, but it needs to be clearly understood that our proposed model does not mean that all GPs have to be actively involved in every aspect of commissioning. A smaller group of primary care practitioners is likely to lead consortia.
I could address many other matters and I am sorry that I do not have time to do so. As I say, I will write to noble Lords. I apologise to them in that the clock is against us. I hope that we can come back to these matters. Suffice to say now that we are living in a financially constrained environment. An extra penny spent on new cancer drugs is excellent. We have the luxury of being able to spend those extra pennies within the confines of a protected budget and of being able to plan on the basis of stable finance over the next three years, unlike colleagues in some other departments. We also have the luxury of being able to plan for higher quality, integrated, patient-centred, outcome-focused health services led by clinicians and patients. I look forward to doing that. Leadership is about making hard choices in difficult times. The choice we have made is to put health first, and the way to do that can be put very briefly—we need to trust the NHS.
My Lords, it remains for me to thank everyone who has participated in a debate which I believe shows this Chamber at its very best. Some direct, penetrating and important questions have been raised and we have had the benefit of informed, expert advice from those who really know what is happening on the ground and who are involved professionally. Specific issues have been debated.
We all respect my noble friend Lord Howe as a caring, compassionate Minister. The way in which he has sought to respond to almost to every point that was raised shows him at his best. Some noble Lords who have participated in the debate are still experiencing the aftermath of a rather difficult election year, but if we are to have a five-year Parliament we face the prospect of just one general election in the next 10 years—perhaps two in 15 years. Many speakers have told me privately that they would love to achieve consensus as the NHS is a great institution. The principles on which it was founded are as important now as they were then—namely, that it should be free at the point of use and available to everyone based on need, not ability to pay. Some still maintain that conflict exists, but the White Paper gives us all a chance to unite to try to create a better National Health Service. This debate is an important step in the right direction as we discuss how best to drive up standards, deliver better value for money and create a healthier nation. I beg leave to withdraw the Motion.