The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
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.
Baroness Thornton
My Lords, the pilots will be running at the same time as the legislation is going through Parliament. I fail to see how that will influence the legislation.
Earl Howe
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.
Lord Beecham
What steps will be taken to ensure coterminosity between consortia and the relevant local authorities?
Earl Howe
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.