(13 years, 3 months ago)
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Lord Turnberg
To call attention to standards of care and the commissioning of services in the National Health Service; and to move for papers.
Lord Turnberg
My Lords, I am delighted to have this opportunity of opening this debate. I am pleased that so many noble Lords are remaining in the Chamber and are going to contribute. I look forward to hearing what they have to say.
I shall focus my remarks on recent reports of failures in standards of care, particularly for the elderly, but this is also a good opportunity to examine whether the commissioning arrangements proposed in the new Bill will have a positive or a negative effect on standards of care. Perhaps, too, we should look at how the Bill might be used to make things better.
I am someone who has spent most of his life working in the NHS and I bow to no one in my support and admiration of what it achieves. I see enormous advances being made every year, and patients who would no doubt have died are now cured and surviving into old age. Medicine has been transformed out of all recognition during my working life.
It is because I have this pride and huge admiration of the NHS and the people who work in it that I now feel a deep sense of shame. Despite these wonderful advances, in too many places we have been ignoring the common decency needed to care for the vulnerable, the sick and the elderly—and it is the elderly who are often the most vulnerable. As Ann Abraham, the Health Service Ombudsman, said in her report, there is a,
“gulf between the principles and values of the NHS Constitution and the felt reality of being an older person in the care of the NHS in England”.
That is why I am going to focus on the elderly, but they are not the only group where standards have slipped. I suspect that other noble Lords may speak about the mentally ill, and only the other day we had a report about failures in maternity services.
Of course, the media are quick to pick up the seemingly occasional horror stories of neglect in a hospital. You might want to hide behind the idea that these are rare incidents against a background in which 1 million people are looked after perfectly well in our hospitals and nursing homes every 36 hours, and that is absolutely true. But it turns out that it is not a rare or unusual event. It seems to be happening far too often, and stories of neglect are just too common for comfort: patients, usually in a geriatric ward, unable to eat the food left out of reach at the end of the bed and collected by staff seemingly unaware that it has not been touched, and too busy to notice that a thirsty patient is unable to even drink without help—or, worse, too busy to notice that a helpless patient, unable to get out of bed and incontinent, is sitting in damp sheets for hours or, the final degradation, soiled by faeces and unwashed for days.
Noble Lords might ask whether I exaggerate. Where is the evidence that this picture is not just a rare, occasional lapse in an otherwise acceptable system of care? Well, quite apart from the rather common anecdotes of many with elderly relatives, there is now the report of the ombudsman in which she describes 10 examples of the complaints she receives that emphasise just how bad it can get.
We cannot say that we have not been warned. In 1997 we had the report from Age Concern in its “Dignity on the Ward” campaign, describing failing standards of care. When it followed that up 10 years later, in 2007, it found that little or nothing had changed. The Commission for Health Improvement in 2003, the Healthcare Commission in 2007 and the Care Quality Commission in 2010, despite regularly changing their names, came up with the same message. Now there is the book that has just been published, Michael Mandelstam’s How We Treat the Sick, which brings all this together in a devastating way.
The scandal at the Mid Staffordshire hospital of a year or so ago turns out not to be an isolated example. Every time we have a disastrous fall in standards we have another report or inquiry. I will not list all the hospitals or nursing homes that have been the subject of criticism but they range from Cornwall to Rotherham, from Tameside to Southampton and from Oxford to Bolton. There are just too many, and it is clearly not a new phenomenon. It went on under the past Government and the one before that, so I do not want to make any political points here. But how can we have tolerated this neglect of our most vulnerable citizens for so long? No one can afford to be sanguine—not the doctors, not the nurses, not the managers and not the Government. I want to say a few words about why and how this is happening and suggest what we might do about it, because we certainly cannot allow it to go on.
Let me apologise for starting with the nurses, for whom I have the greatest admiration and to whom I owe a great deal of personal gratitude. However, at the end of the day, it is the nurses who patients look to first for their personal care and empathy. It is always tempting to look back to a golden age that never was, but one thing that is clearly fixed in my mind is how high the standards of nursing care were on the medical wards where I worked in the 1950s and 1960s. Those were the days when the sister in charge of her ward really was in charge. She was usually a mature woman in a career job who made absolutely certain that everything ran efficiently and well. I admit to running scared of her; as, indeed, did the patients.
However, those were the days before the revolutions in nurse management and nursing education. One of the unintended consequences of the upward drive to better educated nurses with university degrees has been the development of a generation whose aspirations are set high. They quite reasonably expect to have a career in which they can practise their skills to a high standard. Who can blame them? They do a great job with all the caring attitudes you can wish for. However, that has left a gap at the more basic and, to many, less attractive level of the general and geriatric ward where there is greater emphasis on the basic needs of patients: feeding, washing, help with movement, going to the toilet and so on.
Those are the wards where staffing levels are often lower per patient in the belief that they do not need the more intensive, one-to-one care of the specialist units. So they are often understaffed and sometimes come to rely on temporary, or “bank”, staff, who constantly change. Continuity of care is damaged as patients, already a little disorientated by being removed from their familiar environment, are faced with a bewildering series of new faces.
It is not only the nurses who are constantly changing. Confusion is compounded by the way the rotas for the ward doctors are arranged to fit in with the European working time directive or as they rotate through yet another experience to chalk up on their training programme. So there are new faces at every turn. These wards do not have the champions that the specialised departments have, who can put pressure on management to protect them from cuts. Not much wonder that nurses in training pass through those experiences quickly on their way to higher things. Nursing sisters in charge may not stay long enough to be able to stamp their authority and, in any case, are distracted by paperwork or, nowadays, putting stuff into their computers—care plans and the like.
I fear that these changes have created a situation in which we have two starkly different standards of care. On the one hand we have highly trained, highly professional and caring nurses in well staffed specialised units—intensive care, coronary care, chemotherapy units and the like—and, on the other hand, poorly staffed wards, rushed nurses, falling morale, falling standards and poor supervision. These are the staff who are struggling to cope with patients whose vulnerability makes enormous demands for the care and attention that the nurses have neither the time nor the patience for.
Of course, this picture is not true everywhere and many, probably most, wards and hospitals are very good indeed. It is just that this picture is too common for us to take any comfort from it.
So what is to be done? Here it is clear that there is a need for a multifocused set of actions which no one profession or body can shirk. First, we must have someone at ward level who takes full responsibility for ensuring that patients are properly looked after with the respect and dignity that they deserve. That is absolutely key. I hope that my nursing friends will forgive me for saying that we should be making this job, the ward sister or charge nurse, a career post and rewarding those who do it accordingly.
Lord Turnberg
My Lords, there has to be some continuity in that post to make it an attractive alternative to the lofty pastures of the specialised departments.
Then there is the issue of too few carers on the wards. What happened to all those state-enrolled nurses—SENs—whose roles were predominantly in the caring world and who did not aspire to higher degrees? They disappeared in project 2000. Is it possible for us to resurrect the SEN grade and make it attractive again? I hope that some thought can be given to that.
That leads me to the medical profession, who cannot absolve themselves—ourselves—from responsibility for the neglect we are now discussing. They, after all, must see the way their patients are being cared for and, I am afraid, have not raised their voices loud enough. They should be leading the charge for proper staffing levels on their wards. They should be pressing hard on the managers of their hospitals. Of course, they really must do something about these disruptive rotas that are destroying the continuity of care that patients need and deserve.
The managers must make themselves much more aware of their responsibility to ensure that there are sufficient staff on these wards to cope with what is one of the most demanding areas of a hospital. They should know that these wards cannot be among the first, for example, to take cuts. Then there are the responsibilities of the trust boards. Board members have to be rather more hands-on and need to know what is going on in their wards. Many obviously do, but it seems that there are too many who do not.
Finally, I come to those bodies who will be commissioning services in the bright new tomorrow, the GP consortia, and the responsibilities that we should be placing on them for standards of care in the NHS, under the Health and Social Care Bill coming through the House—in whatever form that Bill survives. To paraphrase Aneurin Bevan, there are bed pans clanging on the floor all over the country and, in the rush to devolution to the local level, important though that is, devolved responsibility must also mean some central accountability.
As these services are commissioned, we must make sure that the Bill places a duty on the GP consortia to make sure that high standards of care for the elderly, at least, are a contractual obligation on the providers. Furthermore, we must have a robust system of monitoring so that we can have some confidence that this care is actually being provided. Perhaps the proposed commissioning board can take this on, but only if it has the capacity to monitor what is going on in hospitals and nursing homes, and has a mechanism for action when standards slip.
We have been through too many years in which we have seen indifference punctuated by intermittent reports and wringing of hands. It has to stop. The time for action is now.
Viscount Bridgeman
My Lords, I congratulate the noble Lord, Lord Turnberg, on his timely and most important contribution. We have benefited from his immense and distinguished experience.
The Health and Social Care Bill represents a once in a lifetime opportunity. However, we must not forget that it is built on, and expands in much greater depth, the fundholder initiatives that existed in the National Health Service between 1991 and 1997, when they were stopped in their tracks by the then Secretary of State. I assure the noble Lord, Lord Turnberg, that that is the last political point I shall make. There were, however, some welcome initiatives introduced by the previous Government, of which two were the creation of foundation hospitals and the introduction of practice-based commissioning groups.
The current reforms under the leadership of my right honourable friend Andrew Lansley seek to build on the reforms of the 1990s and the more recent ones of the previous Government and to capture the advantages and discard the disadvantages of both. At the heart of the Health and Social Care Bill lies the increased emphasis on bringing the patient into the decision-making process, and many of the reforms flow from that. Like, I am sure, many speakers today, certainly the lay speakers, I have canvassed the views of a number of general practitioners and consultants. We can of course differ on the overall measure of enthusiasm for the reforms. However, I think it is fair to say that a substantial proportion of general practitioners welcome the proposed changes, while opinion among consultants is more evenly balanced, though here, among the younger age group, the reforms appear to be generally welcomed.
Among the general practitioners there is the age-old agony for the conscientious GP as to how much time he or she will be required to give up for the management of the consortium, at the expense of treating patients. The evidence from the early experiences of the pathfinder consortia shows that many able practitioners have come to terms with this issue and are able to adjust their professional lives around it—and the consortia are at the heart of these reforms. They will take the place of the primary care trusts. What, then, is the difference? The main difference, as I see it, is that the PCTs have seriously little clinical input. This, by contrast, will, I hope, be the strength of the consortia, which will be clinically led. These consortia, to which every general practice will have to belong, will have the resources to back up their constituent practices and will commission secondary care.
The document Liberating the NHS: Legislative Framework and Next Steps is, I suggest, a model of its kind. It is readable, positive and forward-looking. I wish to speak about one of the specific matters mentioned in it—the provision of specialist services. It is known that some disabled charities are concerned that some specialist low-volume and often expensive services which they use will be lost. The paper specifically provides for this by encouraging consortia to work together to share such services, and for these to be commissioned by the NHS Commissioning Board. This is but one example of the many relatively minor issues which have been addressed in the paper and demonstrates the flexibility of the proposed consortia structure.
Much has been made of pathways in the paper, and these are at the heart of the proposals in the relationship, initially, between the patient and his or her GP. If the patient cannot be treated within the practice, the GP will negotiate with medical colleagues in the consortium, who will in turn negotiate with the provider. Note the clinical input at every stage.
Time does not permit me to make anything but passing reference to the very welcome initiative proposed to combine many of the functions of healthcare and social services under the health and well-being boards. The point that the noble Lord, Lord Turnberg, made about the care of the elderly is crucial to this combination. This is a very important and long overdue development.
I asked a GP who had given me considerable help in preparing for this debate whether there was any point that he would like me to make. He said without hesitation, “The NHS has for far too long tolerated poor performance by general practitioners”. I suggest that this is at the heart of these reforms.
Lord Alderdice
My Lords, we are all indebted to the noble Lord, Lord Turnberg, for obtaining this debate. The only unfortunate thing is that he did not obtain more than two hours as that leaves us with relatively little time to discuss an issue about which many of us are extremely passionate. However, as an additional service to your Lordships' House, he introduced the debate with understanding, passion and compassion and identified some very real and long-standing problems in the NHS. I wish to pick up on those as they are of enormous importance.
As the noble Lord pointed out, over a considerable time there has been a deterioration in what I might describe as the culture of care. I say “care” rather than “treatment” because, as he rightly pointed out, specialist, high-quality, acute treatment is often of a very high standard indeed; but in areas such as the one closest to my heart—care of the mentally ill, whether in the community or in in-patient care of various kinds—or care of the elderly, as he rightly pointed out, that long-term care has often deteriorated because of cultural changes in the NHS itself. I shall explain what I mean by that.
As the service expanded and became more complex, there was an increasing and necessary focus on management. It became increasingly the case that those who progressed would move into management. The noble Lord referred to this. In most professions, such as social work, psychology and particularly nursing, if someone wanted to make progress, inevitably they moved out of direct clinical care. For the ambitious and capable young nurse, for example—although this state of affairs was not confined to nursing—to make progress in the profession meant focusing on training and development, to move out of direct clinical care and into management, rather than making clinical care a long-term career commitment.
For obvious reasons, this disadvantaged the concern and commitment of the ambitious and capable young nurse for clinical care; the culture was to move into management. Doctors moved in the other direction. They continued to focus on clinical care—even when they got into management, they rarely gave up care completely—but that meant that they were disadvantaged when they were good managers. They tended to let go not of the care side but of the management side, which increasingly became detached from medicine, so doctors became disenchanted with the whole process of management.
In their different ways, our different professions found that the domination of management in the service took us away to a management culture rather than to a professional culture of devotion and care, which is what our NHS ought to be about. It is that change that we need to find a way to reverse. This is the idea of the reforms that are proposed. They are not necessarily the same as the proposals that will come forward, and it will be your Lordships' responsibility to try to change things in such a way that the principles are best expounded in the legislation and ultimately in its implementation. The challenge is how we move to less management focus in care and to more clinical focus, and focus on the patient.
We must move to greater local accountability; greater clarity of governance; competition in quality of care and not in the price of care, because that will be set down in tariffs; and to ensuring that there is a greater integration and collaboration of the various groups involved—public, private, and charitable and non-governmental, which often produce good-quality niche care in various ways. If we can ensure that progress and do it together—I hope that the exercise will be collaborative rather than partisan in your Lordships' House—we will have something to look forward to despite the difficulties that the noble Lord pointed out.
Baroness Emerton
I thank the noble Lord, Lord Turnberg, for raising this timely debate. Without doubt, corrective action is required to deal with these issues. They will not go away unless that happens. This fact is reflected in the 57 per cent increase on last year in referrals from the general public to the Nursing and Midwifery Council fitness to practice committee in the months of January and February this year. The total was 833—a dramatic increase.
On 3 March, I asked when the Government were going to respond to the report of the Prime Minister’s commission on nursing and midwifery, published in March 2010. I declare an interest: I am proud to say that I am a nurse and that I was on the commission. The Minister replied that he would check where the Government were on the formal reply. I raise this again as no response has been received and because a year was spent by 20 senior and distinguished nurses, midwives and health visitors looking at the problems that faced us.
Evidence was collected following meetings with the public, stakeholders and students, and left the commissioners in no doubt that a “care quake” was approaching—driven by healthcare trends, social changes, demographic changes, families outsourcing care, growing numbers of people with long-term conditions and the additional complex conditions resulting from the ageing process. The nursing professions are centre-stage to handle the care quake, but must be properly equipped and supplied to deliver truly compassionate care that is skilled, competent, values-based and that respects patients' dignity with clear, respectful communication to patients and relatives.
We gathered from extensive engagements with the public that they felt strongly that the public image of the nursing, midwifery and health-visiting professions is out of date and that a new story of nursing is needed. The clearest message was that the traditional image of the front-line sister or leader of a community nursing service should be restored to the former point of visible authority and clear leadership role, answering the cry, “Who is in charge?”, at front-line level.
The commissioners set to work to make recommendations for the largest single workforce in Europe. There are currently in excess of 625,000 nurses on the register. The NHS nursing and midwifery pay bill is £12 billion, with more than £l billion spent on pre-registration nursing and midwifery education. There is little research on the cost-effectiveness and cost-benefit of nursing-led services, and existing research is often ignored. A recent scoping review commissioned by the Nursing and Midwifery Council found that there were 300,000 healthcare support workers in the NHS that were unregistered, posing a potential risk to patient safety. Recently the Mid Staffordshire complaints officer stated in evidence to a public inquiry that the ratio of trained nurses to support workers had swung to 40 per cent trained and 60 per cent healthcare assistants over the period 2002 to 2009. That was a change to address the £10 million overspend in the trust.
The move to make nursing a degree-level profession by 2013 is an integral step in ensuring that registered nurses and midwives have an academic base to translate into high-level, quality compassionate care.
Of the nursing commission’s 20 recommendations, I wish briefly to highlight four. The commission said that the nursing, midwifery and health-visiting professions should deliver high-quality care and that leaders should accept full managerial and professional accountability for ensuring that the organisation provides high-quality, compassionate care. The boards should ensure that care champions strengthen the front-line managers—for example, sisters and charge nurses. There was a call for advanced practitioners and healthcare support workers to be regulated, protecting the title “nurse” and limiting its use to those on the NMC register. This would be equivalent to “enrolled nurse”, as has already been mentioned. Another recommendation was that nurses and midwives should contribute to health and well-being, reducing health inequalities.
I hope that Her Majesty’s Government will respond quickly and positively to the commission’s recommendations, which all go towards achieving an improved nursing profession that will meet the needs of the community with compassion and with respect for the elderly.
Baroness Northover
My Lords, perhaps I may remind noble Lords, as I did in the previous debate, that we have a very tight time limit in this debate. Therefore, when the Clock reaches “4”, noble Lords will have completed their allotted four minutes.
Baroness Sherlock
My Lords, I thank my noble friend Lord Turnberg for securing this debate and I declare a non-pecuniary interest as the next chair of Chapel St, a charitable enterprise which delivers services in partnership with primary healthcare.
I should like to wave another report at the House. This one came out last week. It is from the King’s Fund and is called Improving the Quality of Care in General Practice. In fact, it begins where the noble Viscount, Lord Bridgeman, left off, looking at variations in care. The report was the result of a major inquiry conducted over two years by an independent panel. The panel looked at general practice and found that most care is good, which is a relief, but it also found that there is a widespread variation in performance, as well as gaps in the quality of care delivered by general practice. The report is full of examples, which I commend to the House. It showed variations in the quality of prescribing, in the quality of diagnosis—for example, one-third of patients with stomach or oesophageal cancer who required urgent referral to hospital were given non-urgent referrals—and in the rate of referrals. The report also highlighted variations in the continuity and co-ordination of care. It showed some significant differences.
Almost as telling was the fact that it found a significant problem in accessing public information, particularly comparative data, on performance in general practice. When we consider the avalanche of data available for almost every other part of the health service, that is quite striking, and I should be interested in hearing the Government’s reaction.
I see that the noble Earl, Lord Howe, told the Health Service Journal last week that, in response to the report, the Government’s plans to move 80 per cent of the NHS commissioning budget to GP-led consortia will improve this situation. I am very keen to learn how, and perhaps the Minister will take the opportunity to explain it to the House. He may not want to go into detail today but I wonder whether I can encourage him to assure the House that he will engage with the King’s Fund, as well as with the Royal College of General Practitioners and the BMA. I was delighted to hear that they both welcome the report, so there is a fair wind behind it, but perhaps the Minister will engage with them in looking at how these problems can be tackled. Perhaps, in particular, I could encourage him to do so before this House starts to look in detail at the Health and Social Care Bill that will be coming before us.
For me, this report could be a metaphor for the state of the health service: most general practice is good; the NHS is good; popular satisfaction has never been higher; its efficiency is admired; but there are pockets of significant problems, as described by my noble friend Lord Turnberg. It is clear that performance and outcomes vary too much. We all want to see continuous improvement and we all are open to the idea of changing how healthcare is delivered. However, it is not at all obvious to me how the revolution in the health service, on which the Government are embarking, will necessarily solve these problems. Risks will inevitably be taken by such large-scale reform, so not just this House but the country needs to be persuaded that the changes will produce results that will solve the kind of problems that have been identified. I strongly encourage the Minister to look not just at the specific problems raised but to say why the Government think that their prescription will cure the ills. That is the challenge for all of us.
When I thought about what I would talk about today in my four marvellous minutes, I went back to a list of notes that I had made at the wonderful all-party seminars that many of us have attended with experts in the field, and I found a list of 20 questions to which I did not know the answer. It is not simply a list of questions that I cannot answer, as that would be a rather greater list, but a list of questions to which the experts at these seminars had been unable to find the answers after carefully reading the Bill and all the associated documentation. If that is the case, we have to question the wisdom of proceeding at the current pace. This House has enormous respect for the integrity and experience of the Minister. I wonder whether he could speak to his colleague the Secretary of State and encourage him to reflect on the fact that a wise man does not demolish his house while the architects are still sketching the new one.
Baroness Hollins
My Lords, I, too, am somewhat daunted about speaking about my interests in this debate in such a short time, but I am grateful for the opportunity. I note that the Care Quality Commission has just published its second annual report. Encouragingly, it talked about safer services and an upward trend in the standards of healthcare.
Noble Lords would expect me, as a former president of the Royal College of Psychiatrists, to speak about people with mental illness and learning disabilities. I shall do that but I will focus on the physical health of people in that group and their access to acute hospital services. That relates to commissioning. Although I do not think that commissioning is the key to all the problems in the NHS, strong commissioning is important. At the moment, commissioning largely does not understand the needs of people with learning disabilities and mental illness, particularly when their needs are complex and they are seeking care in an acute hospital setting. I shall try to explain what I mean and will give two examples.
If we stop to think about maternity services—my noble friend Lord Patel may have a different view—we find that the most complex kind of maternity case is a mother with a severe mental illness. However, the current tariff does not cover the mental illness that that mother has and the obstetric department does not have to purchase mental health services to look after that mother. That is a real shame, as this is a good moment in a woman’s life to attend to her mental health needs and the mental health needs of her child. That is just one example.
The Bill sets out clearly the kind of duties that commissioners will have in the future and suggests that commissioners will need to seek advice, but what kind of advice is not clear. GPs will need to work closely with their clinical colleagues in different specialisms, particularly specialists in mental health, to ensure that their patients with mental illness get their ordinary, everyday healthcare needs supported and adequately met, and not just their specialist needs.
People who do not work in psychiatry often think that commissioning for mental illness or learning disabilities is about buying specialist services somewhere else and that it has nothing to do with the rest of the health system. That is just not true. There is no health without mental health and I am pleased that the Government’s policy on public health acknowledges that.
Because I have less than a minute, I shall turn only briefly to learning disability. Tom Clarke MP spoke in the other place yesterday about the NHS and public satisfaction. He spoke extremely eloquently and, since I do not have time to repeat all that he said, I encourage noble Lords to read Hansard. He talked about the long history of concern of Mencap and other bodies about the institutional discrimination that has been found in the NHS—not a culture of care but a culture of discrimination. The previous Secretary of State established an independent inquiry into healthcare for people with learning disabilities. It came up with some important recommendations, including recommendations for training all healthcare professionals. I would appreciate support from the Minister for such recommendations to be fully implemented when the new Bill comes in.
Lord Winston
My Lords, the points that I shall make are no criticism of the Government; indeed, they are not faults induced by them. If there have been faults, they have been those of healthcare professionals and the management of the health service. I hope that the noble Earl will be able to respond by saying how we can build in these suggestions. This is a strong echo of what the noble Lord, Lord Turnberg, said. He spoke with nobility, dignity and humanity and his points were very well made.
Some weeks ago, I brought to the attention of the House my experience at a leading hospital, where I was faced with a woman in her postnatal period, four days after delivery, with a dangerously high, life-threatening blood pressure, which no one was dealing with—she had not seen a doctor in four days. There was no continuity of care on the ward. When I tried to speak to the nurses, they were busy at their computers and with their paperwork.
I want to talk about the loss of continuity of patient care in the hospital service. The noble Lord, Lord Turnberg, talked about halcyon days. Although we may not want to return to those days, the old-fashioned firm system in medical practice was very good: the idea of consultants working in tandem, usually two at a time with the same secretarial support, followed by a senior registrar, a registrar, house physicians and house surgeons, was a good way to ensure continuity. Nowadays, we do not even have the privilege of interviewing the staff who come on to the team. Because of political correctness, they are often appointed. That means that we lose a valuable kernel within the health service.
There used to be flexibility about time off. We did not go off when a patient was really sick. We had a detailed handover when we went off, if we had to. We would make sure that the person to whom we were handing over understood what was going on. We were still responsible, as junior doctors, when we were off, and would expect to be informed if critical decisions were being made about those whom we regarded as our patients. That ethos and that culture have been lost, partly because of the European working time directive, although that is not the only reason. The restrictions on working time, which we have previously encouraged the Government to think about, have had a massive negative effect not only on training and experience but on morale and continuity. A “watch the clock” attitude has been engendered.
There used to be general ward rounds for the whole team, at which the ward sister would be an important person, together with the general practitioners. Often, general practitioners came to the wards, which meant continuity in society afterwards. Nowadays, we do not have the same attitude towards the hospital in which we work. We have no hospital nurse, no medical porters and no dedicated bedrooms. There is no staff dining room. That may seem a ridiculous point, but the disadvantage is that, in terms of morale, we cannot replace the staff dining room, where we used to discuss individual patients with other consultants in order to learn. In science units, restaurants and coffee facilities are in every research lab, but they are no longer in hospitals. We should think about that. I have to say that I learnt my haute cuisine of Indian cooking in such messes. We felt valued members of an institution in a way that we do not now.
As the noble Lord, Lord Turnberg, said, there is no leadership on the ward. Without ward sisters, individual nurses do not feel responsible for all the patients in their care on the ward. Doctors now normally do ward rounds without the sister present; indeed, it is difficult to find a nurse who is free.
I make one final point. Basic nursing has been lost: cleaning patients, caring for them, listening to them, trying to feed them occasionally. Yesterday, I met a paediatric nurse at one of the best nursing schools in the country. She said: “I got an A in hospital management and NHS management in my essays, but I cannot change a paediatric colostomy bag, and that really worries me”.
Baroness Benjamin
My Lords, I thank the noble Lord for securing this debate. Sadly, his opening remarks reflect the treatment that my late 80 year-old father received during his last months, which were spent in hospital.
This debate gives me an opportunity to highlight the concerns of those with sickle cell disorder as well as of those working with and for patients with the disorder. I am a patron of the Sickle Cell Society, so I declare an interest. The Sickle Cell Society has a panel of expert medical advisers as well as a board that includes those who suffer from sickle cell disorder. Over the past 30 years, the charity has worked with the NHS and primary care trusts to produce best practice guidance on treatment and care based on clinical research and the experience of those with sickle cell disorder.
Sickle cell is the most common genetic blood disorder in the UK and some 300 babies are born with sickle cell each year. Yet children and adults are needlessly dying from this illness. The two most recent deaths were in the past four months—one as young as four years old. The deaths are due to poor access to services, poor care, poor treatment and generally poor awareness of the disorder. The National Confidential Inquiry into Patient Outcome and Death shows that of the 19 patients it studied who complained of pain on admission to hospital and who died in hospital, nine had been given excessive doses of medication, leading to death from the complications that resulted.
I believe that with the right policies in place and an understanding of best practice standards, treatment and medication, the quality of life for sickle cell patients can be dramatically improved. Will the Minister consider a medical and social awareness campaign, backed up by syllabus changes to medic training at royal colleges? Will he also consider commissioning services to improve the detection and chronic disease management of patients with sickle cell? I am convinced that if these measures were in place, it would save the NHS millions of pounds, prevent many deaths as a result of hospital overmedication and reduce children being absent from school, which produces poor educational performance that in the long term leads to economic disadvantage and benefits claims.
I believe that the doctor-patient relationship is a two-way dynamic. Some changes to the current system are required in terms of GP education, follow-up, and long-term involvement with the management of sickle cell disorder. Patients and healthcare providers should work together in the proactive management of sickle cell disorder, rather than dealing with crises on an unplanned basis as and when they arise.
The current financial state of the NHS and the recent spending review have increased the nervousness of sufferers. Therefore, there need to be reassurances about the funding of provision for sickle cell. Some believe that the abolition of health targets will have a negative impact and that services will not provide fairness and equality of access to healthcare services for all. Therefore, there needs to be NHS specialised services commissioning for those with sickle cell disorder, with provision for practical home-care support, especially home-from-hospital convalescent support to avoid readmission, the training and deployment of a pool of community support care workers, information and counselling to every patient and carrier in every locality, and the monitoring of performance against agreed outcome measures. I believe that the Sickle Cell Society is well placed to assist the Government in achieving these measures.
Sickle cell disorder should be of great concern to society. It needs our full attention because as more and more children are born to parents from different ethnic groups and we become more and more integrated, so the more common sickle cell disorder will become. Sickle cell disorder is now the fourth global public health priority, as declared by UNESCO and the World Health Organisation in Geneva in May 2006. Please let us accord it the priority and respect it deserves.
Baroness Murphy
My Lords, I shall hark back to much of what the noble Lord, Lord Turnberg, said in his admirable introduction to this topic. The stories in the ombudsman’s report are so shockingly familiar to us, yet we still find it very difficult to take in that they reflect the norm. The National Confidential Inquiry into Patient Outcome and Death in surgery for elderly patients found that only 38 per cent got good care. It is not just that care is neglectful to the point of cruelty, but that families that try to intervene are actively discouraged and largely ignored and the denial by managers is a cultural norm. I found that I could not save my own mother-in-law from truly appalling care in a suburban London hospital, and my own mother’s recent care in a Midlands teaching hospital was pretty variable, too, depending on the team that was on duty.
I have heard people minimise the significance. Apparently the NHS has improved over the past few years and patients say that they are very satisfied with the care that they get. It may well have improved, but the very aged do not respond to these patient surveys, and in any case it is their distressed kith and kin we should be surveying to get an accurate picture. My mother would not let me complain because they fixed her hip, did they not? The Patients Association has been flagging up the truth for years and the majority of senior managers know that Mid Staffordshire Hospital was not an outlier on the graph by any means.
The usual response to a scandal is to launch an inquiry, and I have sat on many myself. Typically they make vast numbers of recommendations that are then translated into points for action with a monitoring schedule for ticking off the boxes. Schedules will be cascaded and all will get a bit better. There are marginal improvements locally, but nothing really changes. What is the answer? More inspection? I do not think so. The CQC knows that the self-monitored standards of dignity that hospitals claim to have reached are often a fiction. Inspection never picks up more than a snapshot. Unannounced visits are helpful, but they are too infrequent and superficial to be realistically helpful. Regulators simply cannot substitute for caring staff. More training that treating old people appallingly is wrong? I do not think so. We all know it is wrong, but we learn by example from our seniors. If that counts as training, then perhaps training is needed. More geriatricians and psychogeriatricians like me? We need champions in medicine and nursing—but no, this is every clinician's business, not a specialty.
I agree with many colleagues who have spoken before that getting the teamwork and ward processes right might help a bit. It is noteworthy that these episodes of poor care do not occur on specialist wards where unified teams work together under good leadership. We have tended to undermine teams on general wards in the misguided and counterproductive chase for efficient turnover. I harp back to Professor John Yates’s earlier studies, which show that it is vulnerable patient groups, local ward staff left to their own devices and staff not included in team support who fail.
My recipe comes back in part to unannounced regular inspections by HealthWatch and the regulator and to surveys of family carers. However, hospitals reflect the wider attitudes of society. We should look properly at the price of care, and we should stop commissioning specialties such as cardiac, cancer and renal at a higher tariff on the care price compared with medicine for the elderly and general surgery. The funding imbalance is profound and reflects the poor value which society puts on the everyday care of the most vulnerable. Therefore, the commissioning sensitivities that GP consortia will have will be crucial. We know from studies in the States that commissioning cannot be the whole answer; it is the providers who are important. However, we should not necessarily ignore commissioning. It is vital, but ultimately it is the care design in hospitals and structures that really count.
Lord Owen
The NHS is dear to us all, and the care and health professions have made a difference to pretty well every family in this country. However, the 353 pages of the Health and Social Care Bill are a massive reform, and we should not underrate the basic fatal flaws in this legislation, although of course there is much that we can all recommend and be pleased to see.
The health service is a rationed service. A lot of the acceptance of and satisfaction with that rationing has come from its democratic basis and the feeling that it is done in a democratic and acceptable way. That is challenged by the Bill and by a massive change in the responsibilities of the Secretary of State. The fatal flaw is to move on from the internal market—a reform introduced by successive political parties that was initially quite controversial but, I believe, has done a lot to encourage cost-effectiveness and efficiency in the health service—and to cross that threshold to an external market.
This Bill needs to be substantially amended, not just at Report stage in the other place—it has not yet been amended in Committee—but when it comes to this House. In my view, it is not in the interests of anyone to include “any willing provider”, which would inevitably involve EU competition law and legal cases about commissioning decisions. Nor is it in anyone’s interest that we should make costs and pricing the basic decision on where a patient is allocated. That would have profound effects on the relationships between patients and the general practitioners, consultants and managers who have to make these rationing choices.
Deep and fundamental problems underlie this Bill. I hope that when it comes to this House we will use the unusual but nevertheless precedented position of giving it a Second Reading but only on condition that it is referred to a Select Committee of this House in order to give it far deeper and more fundamental attention. This Bill should have had a full pre-legislative committee. It has not got it. Listening to this debate, it seems to me that we are not reflecting the anger, disillusionment and despair of many people outside this House about this legislation. Were the Bill to pass in its present form, it would do horrendous damage to the health service—not immediately, but slowly and imperceptibly. It would also damage the professionalism, care and intimacy of the one-on-one patient-nurse and doctor-patient relationships, which I believe are so essential.
Health is not just a commodity to be bought and sold in the market. It is not a utility in which everyone should be treated as if they are commodity managers. We must understand that and the fundamental issues which are being challenged by this Bill. Perhaps they are being challenged inadvertently but, nevertheless, that is happening. Extensive amendments have already been talked about. Why was the Bill in that condition? I urge this House at Second Reading to refer it to a Select Committee—perhaps for six months until after the Summer Recess. Then we could come back to the normal amendments and, if necessary, the ping-pong between both Houses. Ultimately, I would not hesitate to delay this Bill for the statutory period if the House of Commons does not accept amendment procedure in this House. Fundamental amendments are needed. This is not a minor piece of legislation or a part of the evolutionary change we have had since 1948; it is a revolutionary change and, in some parts, a very bad change.
Baroness Pitkeathley
My Lords, I thank my noble friend Lord Turnberg and declare two interests as chair of the Specialised Healthcare Alliance and as chair of the Council for Healthcare Regulatory Excellence.
However devoted we are to the NHS—I speak as one who owes her life to it—we must acknowledge that there are still far too many instances where it falls short. No one could fail to be shocked by the ombudsman’s report to which many noble Lords have referred. The universal standards which we all wish to see, of a compassionate and skilled service, are by no means universal as yet. The dismissive attitudes and indifference to deplorable standards encountered in all too many instances must be addressed and, as far as possible, eliminated. I say “as far as possible” because, as a regulator of healthcare, I know only too well that it is not possible for any form of regulation to bear on every safety or quality concern. We are dependent on the quality of the professionals delivering the service and we must judge this always from the experience of the patient and his or her family.
When we think about commissioning as being about improving health outcomes and reducing health inequalities, let us never forget what that means from the patient’s point of view. Most will have absolutely no idea what “improving health outcomes” means. They only know that they want to be treated safely, with dignity and compassion, and have timely and effective treatment. In all the discussions we are currently having about the reform of commissioning, I am often struck by how remote those discussions seem from the actual experience of patients. The test that we must apply is whether it is better for them, not whether it is better for the Secretary of State, the commissioning board and GP consortia.
It is also striking how removed our discussions are from the facts around patients’ experience, which are not linear but confused and complicated—a mixture of services from health, social care, housing, the voluntary sector and their own families. This complication of experience is little recognised, even now when some of us have been trying for 30 years to get it recognised. The question we have to ask is: will the new commissioning arrangements deliver that recognition? We do not know.
What we do know is that every bit of research ever done about changing institutional structures shows that only a part, and usually a small part, of the objectives are achieved, and the bigger the upheaval, the fewer of those objectives are achieved. Since we are largely dependent for quality outcomes on the skill, commitment and—let us not be afraid to use the word—dedication of our staff, how are we to maximise those and provide them with the support they so urgently need when, for the next two years at the very least, their energy will be directed towards the change itself in the form of applying for their own jobs, learning to work with a new set of partners and so on? Also, the history of co-operation between GPs and social services does not fill me with hope, while the lack of co-terminosity between consortia and local authorities is certainly not going to be helpful.
We know that the commissioning board will issue guidance on commissioning to the consortia, but when is this to happen? Do we not risk a mismatch in timing? Some of the consortia are already willing to go ahead and are following their own rules in the absence of any from the commissioning board. I hope that the Minister will be able to comment on this. Also, from the patient’s point of view, we need a great deal more clarity about what will happen when GP consortia refuse to commission a service that a patient requires. Where is the accountability?
As to the voluntary sector, for so long the provider of good preventive care and services, we hear a great deal about organisations being encouraged to take on a greater share in providing public services and for the commissioners to recognise this. If we are serious about pushing power as close to individuals as possible and for citizens and communities to define the priorities and expectations of public services like the NHS, as the big society concept suggests we should, it is certainly important for the voluntary sector to be involved. However, many organisations are having their funding savagely cut, and more than half of them say they are going to have to cut staff in the next three months. Given that, I doubt their capacity.
Lord Rooker
My Lords, there is widespread concern among nurses, patients and relatives about the many incidents of poor nursing highlighted in recent years. There are of course many fine examples of high-quality nursing practice, and I can testify to that from my own family experiences. But action now needs to be taken to improve the state of nurse training and management. Over the past five years, a nurse friend of mine, Sheila Try, has been contacting successive Health Ministers, Select Committees and others with these concerns, as well as the Chief Nursing Officer, all to no avail. They have all failed to see that there is a fundamental flaw in the training and management of nurses and that the image of nursing has been damaged. The Chief Nursing Officer commented to Sheila that these,
“concerns resonate very well with nurse leaders who I have met around the country and with the wide range of people who explain their experiences to the Prime Minister’s Commission, ‘Frontline Care’”.
That is a clear admission of the points that Sheila and other experienced nurses are making.
Sheila Try is a qualified nurse and a health visitor to BSc standard, and a former senior manager and a reviewer for the Commission for Health Improvement. She is not someone who wants to turn the clock back, but she is concerned with the basic essentials of nursing. Last week, she met over 70 third-year degree nursing students at a local university who are due to qualify in August. They stated that they,
“do not feel confident or competent to work as staff nurses as the training has failed to give them the knowledge and skills they need, with clinical placements being too short. There are inconsistencies in clinical practice and Health Care Assistants are doing nursing tasks, including wound dressings, while they as students are doing Health Care Assistant roles (handing out drinks) when they should be being trained in nursing tasks”.
The students are concerned that their competencies are usually decided on just one observation of the skill required, such as catheterisation or wound care. They would prefer a more rigorous check in order for them to feel competent and confident. On learning to drive with an instructor, you do not do a three-point turn only once.
One of the issues lies in the ratio of academic to clinical practice. The time spent in contact with patients is only 15 weeks in each of the first two years over two placements and 21 weeks over two placements in the final year. That is not enough. This is not resulting in well trained nurses capable of giving good, consistent quality care at the point of qualification.
Image and esteem are important. These have been damaged by the practice of not using the title of “nurse” and the poor national uniform that was introduced some years ago. After working for three years to become a nurse, people are told not to use the title, but to tell patients their first name, which is unprofessional. The sign above the bed says, “Your nurse is Susan” or “Mark”, but not “Nurse Jones” or even “Nurse Susan”. That is ridiculous because it is unprofessional and breeds a familiarity that can cause problems.
The uniforms that nurses wear in most hospitals are not very professional, with qualified nurses wearing the same uniform with no difference in design to identify their status. The uniforms are often of poor quality. Nurses have said that they are more like a cleaner’s overalls—that is not to degrade cleaners. This affects not only the image that the uniforms portray to patients and relatives but also how nurses feel about themselves.
One major hospital in the Midlands has recently changed its uniform policy, bringing in colours to identify a nurse’s grade and with the grade embroidered on the uniform. Patients and relatives can now distinguish between a staff nurse and the sister in charge. It has massively lifted morale, because the nurses feel valued. The ward management points that Sheila has asked me to make are exactly the same, word for word, as those made by the noble Lord, Lord Turnberg. The solution, she thinks, is simple: tackle the way in which nurses are trained, with more time spent with patients and less in the classroom.
Nursing needs to be up to date with technology and the changing face of disease and management, but essential care is vital to ensure patients’ safety. A better balance between academia and professional placements, needs to be found. And, yes, Nurse Try would welcome an opportunity to put the case to the Minister direct.
Baroness Tyler of Enfield
My Lords, that is a hard act to follow. I congratulate the noble Lord, Lord Turnberg, on securing such an important debate at a time of far reaching reforms to our National Health Service. These reforms should be judged by the extent to which they lead, first, to better health outcomes for adults and children; secondly, to consistently higher standards of care for all; and, thirdly, to a more responsive and personalised service. Given the scale and pace of reforms, the most radical in a generation and beyond, it will be crucial to give close attention to the quality of care during this period of immense change.
I would like to illustrate this by talking about the standards of care and commissioning practices within mental health services, still seen in some quarters as a Cinderella service. I am indebted to the briefing and support that I have received from the charity Mind.
One in four people is likely to experience a mental health problem every year and the cost of poor mental health to the economy is estimated to stand at £105 billion. As will be well known in your Lordships' House, mental health problems are inextricably linked to social factors such as debt, unemployment, poverty and poor housing.
The Government’s recent No Health without Mental Health strategy sets out a clear vision for the future of our mental health services. This is to be welcomed. The strategy also makes it clear that the provision of high-quality services is dependent on high-quality commissioning.
To make a reality of that strategy, it will be important to ensure four things: first, that commissioning bodies have a proper understanding of mental health services and service users; secondly, that mental health services are fully integrated both within the health service and across social care, public health and areas such as housing and policing; thirdly, that every opportunity is taken to increase patient and public involvement and that those who need extra support to get involved in decision-making are given it; and, finally, that there is parity of esteem between mental and physical health services.
In response to a recent survey by the charity Rethink, 42 per cent of GPs said that they lacked knowledge about services for people with mental illness and lacked confidence in commissioning those services. The abolition of the National Mental Health Development Unit this very day will create a real gap in mental health advice for commissioners and providers. What plans do the Government have to fill that gap in expertise?
The Government have recently announced plans to invest around £400 million over four years to ensure that adults with depression and anxiety across England have access to a wider range of effective psychological therapies. This investment will also enable the expansion of much needed psychological therapies for young people, older people, people with severe mental health problems and people with long-term physical health conditions. All this is greatly to be welcomed but it is vital that this funding is not seen in these tough financial times as an opportunity to cut existing mental health services.
As already referred to, only this week the Care Quality Commission released its latest report on the state of health and adult social care. I was concerned to see that, despite the welcome advances across the board, care standards for people experiencing mental health problems are being left behind, particularly in acute and crisis mental health care.
I would have liked to have finished by saying a few more words about the commissioning of children's mental health services—an area that I know something about. I am chief executive of the charity Relate, a declared interest of mine, which has experience of providing what is called early intervention counselling services. Time will elude me, but the one thing that I will say is that far too often the voluntary sector finds itself left to pick up the pieces because statutory services such as children and adolescent mental health services, which try to do a good job in very difficult circumstances, are vastly oversubscribed with very long waiting lists. More needs to be done to give this area higher priority.
Lord Touhig
My Lords, I join others in the House in thanking my noble friend Lord Turnberg for securing this debate. In the short time that I have at my disposal, I would like to focus my remarks on one area in particular: healthcare and autism. The noble Baroness, Lady Browning, and I, together with representatives of the National Autistic Society, recently met the Minister and we were given a very sympathetic hearing on matters that concerned us. We thank him for that.
The National Audit Office’s investigation into public spending on autism found that one of the best ways of overcoming the alarming gaps in training, planning and provision across a range of services was to develop specialist autism teams that could diagnose and support people with autism. It went on to say that, if such teams are established, there is the potential to save money. It stated that, if local services identified and supported just 4 per cent of adults with high-functioning autism and Asperger’s syndrome, the outlay would become cost neutral over time. In addition, it found that, if these local services did the same for just 8 per cent, the Government could save £67 million per year. The Liverpool Asperger Team, which is the longest-standing specialist Asperger’s service, reports an identification rate of 14 per cent, so 4 per cent is certainly achievable.
Will the Minister tell the House how teams such as the one in Liverpool will be funded if the Health and Social Care Bill is passed into law? In the Bill, health and social well-being boards have a duty to promote integrated working and, as such, would lead on commissioning specialist services. However, the White Paper published in July states that the NHS Commissioning Board will take responsibility for commissioning specialised services at both national and regional level, as informed by the specialised services national definitions set. These sets contain definitions of 34 services. Definition 22 covers specialist mental health services and includes specialised services for Asperger’s syndrome and autism spectrum disorder. There is clearly a difference between the White Paper and the legislation on how specialist autism teams will be commissioned to carry out their work. Will the Minister say whether the NHS Commissioning Board or, at local level, the health and well-being board will be responsible for this commissioning work?
Each of the commissioning scenarios is not without problems. First, specialist teams are often commissioned through pooled budgets. There is concern that, if 80 per cent of the commissioning budget sits with the GP consortia but the health and well-being boards are responsible for commissioning the joint services, the major budget holders—the GPs—may not commission services whose primary benefit in the short or medium term will be the local authorities. The commissioning problems could potentially become more complicated when health and well-being boards have a number of consortia in their areas. It is possible that the GP consortia might take a free ride and not contribute. Secondly, if these services are commissioned through the specialised services national definitions set at regional level, that could make it more difficult for the teams to respond to local needs and integrate themselves into each local authority that they serve.
The draft NICE guidelines on diagnosis, recognition and referral of autism in children and young people call for local teams to be created in each area. Teams such as the ones in Liverpool and Bristol are doing first-class work. A key way of getting over this problem of commissioning specialist teams is to strengthen the role of the health and well-being boards in creating pooled budgets and to ensure that the NHS Commissioning Board can intervene in any disputes over these budgets. I appreciate that this is a major problem still to be solved and I hope that the Minister will respond to that and to my other questions.
Lord Patel
My Lords, good healthcare systems deliver good standards of care and good commissioning should reflect that. I would like to focus on cancer, the insights that it offers into the performance of our healthcare system and the challenges that it poses in the new healthcare structure. The proportion of deaths attributable to cancer has risen from 17 per cent in 1948 to 27 per cent in 2008. It is predominantly a disease of the elderly. Alongside its human impact, cancer is also costly. The National Audit Office estimates the cost as £6.3 billion and the total cost to society as £18.3 billion. These costs will rise as the population ages and new treatments are developed.
Cancer survival is a key metric of the performance and quality of healthcare systems. It is a function of the population awareness of cancer symptoms, primary and secondary care assessment and referral, treatment quality and effective screening programmes. Each year around one in three people is diagnosed with cancer and one in four will die of cancer.
The Lancet in January 2011 compares the survival of patients diagnosed in England, Wales, Northern Ireland, Denmark, Norway, Sweden, Australia and Canada. All these countries have comprehensive cancer registration and broadly similar healthcare spending and systems. The study examined relative survival—the excess deaths due to cancer after allowing for competing causes of death—from 1995 to 2007. Despite the improvement in cancer survival in the UK, the survival gap—the difference between the UK and the best-performing nations—appeared to have showed only some narrowing in breast cancer but was static in colorectal and ovarian cancer and worse in lung cancer. The difference in survival in lung cancer is equivalent to at least 1,300 avoidable deaths each year if we matched the best in Europe. It has been estimated that this survival gap from England to the best-performing countries in Europe for all cancers accounts for 10,000 avoidable cancer deaths each year.
The healthcare system in the UK is not improving at a fast enough rate to narrow the survival gap. This accounts for thousands of avoidable deaths each year. A far greater proportion of people die within one year of cancer diagnosis in the UK than in better-performing countries such as Sweden. This is due to later diagnoses in the UK; when patients in the UK are diagnosed with cancer, it is more often at an advanced stage where survival is shorter.
The coalition Government published in January Improving Outcomes: A Strategy for Cancer. This strategy aims to deliver health outcomes that are among the best in the world. It aims to do this alongside the seismic reforms that are taking place in healthcare in England. These new reforms as they stand rely on high-quality information and organisation of cancer services. The strategy does not ensure the continued existence of cancer networks, but says that,
“it is likely that GP consortia will purchase services from a new style of cancer network”.
That does not go far enough. Cancer networks are essential organisations to ensure the delivery of improved cancer outcomes and, in particular, the geographical areas that allow robust outcome data to be derived. The centralisation of cancer services since the NHS cancer plan has helped to deliver improvements in cancer outcomes. The National Cancer Intelligence Network is now providing detailed cancer outcome data according to network, PCT and age. These powerful data can be used to improve outcomes.
Much of the variation in outcomes in cancer is due to late diagnosis or referral by general practitioners. There is no process in place for assessing the quality of GPs in the assessment of patients with potential cancer symptoms. The Teenage Cancer Trust survey reveals that one in four teenage cancer patients visited their GP four or more times before referral to hospital. Without cancer networks, there is a danger that the cheapest services will be purchased that meet basic but not world-class quality standards. Healthcare is a complex process and we will never be able to define and record every metric that will contribute to high-quality outcomes. I hope that the Minister will confirm today that there are no plans to abolish the cancer networks.
Lord Warner
My Lords, I am grateful to my noble friend for securing this warm-up debate before the Government’s legislative juggernaut reaches this House. In the time available, I want to confine myself to talking about commissioning because good commissioning has a significant impact on achieving good service standards. For 20 years, we have been trying to establish an effective NHS commissioning system. Ken Clarke’s GP fundholding and partial purchaser/provider split was followed by Labour’s PCT commissioner model, again without a full purchaser/provider split. Just for good measure, I added on a practice-based commissioning dimension in 2006 which many PCTs were pretty effective at thwarting. Now we are to have another legislative go. That is a summary of the history of commissioning.
All too often, PCT commissioners have lacked the know-how, competence and muscle to commission effectively. Too often, they have been unable to manage demand, keep in check acute hospital expenditure and hold hospitals to account. We know from the Care Quality Commission data that there are too many PCTs with poor track records on quality and financial management. The House of Commons Health Select Committee’s excellent reports on PCT commissioning make for depressing reading. It is not, in my view, unreasonable to decide that PCTs have had their chance and failed overall, so we should try a more clinically driven model of commissioning, as the Government wish to do. In many ways, this is a logical development from practice-based commissioning. However, the Government must learn the lessons of past mistakes in designing a new commissioning model if they are not simply to repeat those mistakes.
The population size of many commissioning bodies has been too small for effective health-risk pooling. When I hear the BMA say that there is a new commissioning consortium with a population of 18,000 people, I despair. I managed to reduce the number of PCTs from 302 to 150, but could not secure agreement politically to go down to 50. That would have given us commissioning bodies with populations of about half a million to 1.5 million people. I believe that is the kind of population we should be looking for in commissioning the full range of services that the Government wish to give to those kinds of consortia. The amount of high-quality commissioning capability in the NHS that we had in 2005 was insufficient to service the number of bodies involved. That remains the case today and the added trouble is that the amount of money available to pay for them has become even smaller in size.
When the Bill comes to this House, we are going to have to probe the area of commissioning forensically. We will need to ensure that there is a proper system of licensing or accrediting commissioners, however the function is organised. We need to ensure that commissioning bodies have the data collection and the analytical, financial, contracting and clinical expertise to commission safely and cost-effectively the range of services that they will be legally required to commission with about £60 billion of public money a year, on present estimates. The National Commissioning Board must have the authority and capacity to prevent people without the competence to commission getting their hands on big slugs of public money. The board has to be able to remove and replace inefficient, incompetent or overspending commissioners in a timely way. Those are the kind of issues we should be considering when we come to that Bill.
In conclusion, as a former commissioner of social care I found it jolly useful to have a diversity of service providers so, unlike a number of people, I congratulate the Government on going for a bit more competition and extending the market for providers—not just from the private sector but with good providers from within the NHS and good mutuals, of which I suspect we will see a lot more in future. We will have a lot of time to discover what the Government’s thinking is on some of these issues as we take the Bill forward in this House.
Baroness Thornton
My Lords, I start by thanking my noble friend for initiating this debate and for emphasising the importance of standards of care and of the effect on patients of the proposed changes to the commissioning regime. Indeed, I congratulate all speakers in this debate. On this occasion, the point of my noble friend’s remarks was possibly, “We’re all in this together”, in dealing with the standards of care. However, he also said that we face some major challenges here, which are the challenges that he posed, as did several other noble Lords, including the noble Baronesses, Lady Emerton and Lady Hollins, and my noble friend Lady Sherlock. The question is: will the Bill help or not?
I welcome the noble Lord, Lord Owen, to both this debate and our wider discussions. I look forward to reading his pamphlet, Fatally Flawed, this weekend, and I suggest that the Minister might choose to do the same. However, I will resist the temptation to join the noble Lord in what would be a Second Reading speech.
I start by quoting a young woman who works in healthcare and who spoke last Saturday to between 200,000 and 500,000 people—personally, I think it was nearer the latter. In many ways, her simple eloquence says it all about how thousands of dedicated health workers feel. She said: “I am an NHS physiotherapist and have been for 13 years. My patients are people living with complex disability from conditions such as MS, brain injury, spinal cord injury and stroke. I work with a wonderful team of NHS workers such as occupational therapists, speech therapists, psychologists and rehab assistants, as well as social workers, to support our patients to overcome barriers to their independence, often supporting them back to work and working with their carers to support them to stay in their homes for as long as possible … David Cameron told you all in his election campaign that he would ‘cut the deficit, not the NHS’. Well, if 50,000 frontline NHS posts at risk doesn’t count as a cut, I shudder to think what does … For the sake of my patients, I fear the introduction of ‘any willing provider’. I fear that it will fragment services, will make the postcode lottery of care worse, and the most vulnerable patients, those least able to stick up for themselves—the kind of patients I treat every day—will be hit the hardest. Good quality patient care relies on good communication. How can we guarantee this, when services that currently work together are pitched into direct competition against each other? … In parts of the country, physios are already starting to see the rationing of care to just one or two treatment sessions, regardless of need … This is not the NHS I signed up to work for. I don't believe it is the kind of NHS that people in this country want”.
In this short response to the debate I am going to argue that we would not start here with reform and I will ask some questions about the risks to standards of the proposed commissioning system. I put a plea to the Minister: could we perhaps have some new words in his answers to these debates? I have looked back at the debates and discussions in the House since the White Paper was published last July, and time after time the Minister has stuck admirably to the Andrew Lansley brief, with what is becoming the famous NHS techno-jargon that weaves a web of words but really does not serve to comfort, or even leave one any the wiser. It is very noticeable that when the Minister comes off script and is back to his old, clever self, we prefer it and I, for one, understand things better.
We are nearing the point, after many questions and sustained criticism from professionals, patients and even the Minister’s partners in the coalition, when we need some real answers to real concerns, not least on the commissioning that is the subject of this debate. Notwithstanding the progress of the Health and Social Care Bill, I invite the Minister to agree that there is no doubt that the period 2011-14 is likely to be the most challenging ever faced by the NHS. The NHS is faced with the challenge of producing £20 billion in efficiency savings, putting considerable pressure on the system to maintain current standards of care. Given those constraints, we on this side of the House are still of the view, perhaps even more so now, that this is not the right time to embark on the largest structural reorganisation in NHS history, which includes scrapping those layers of the NHS structure with real experience of commissioning—family care trusts and strategic health authorities—and putting the power in the hands of untested and inexperienced consortia.
I am not saying that PCTs and SHAs have been unfailingly brilliant; in some cases, they have not even been good or average. There was and is significant room for improvement, and I think we would all agree on that. Most notably, clinical leadership and engagement in PCTs has often been weak, local accountability has been lacking and imbalances in status and power that exist between commissioners and providers appear to have limited substantially the former’s ability to influence service provision, to say nothing of the lack of clinical presence in the whole process. However, we believe that it would have been better to tackle this problem rather than to turn the whole NHS upside down.
What of the transition? Responsibility for maintaining and improving the quality of services will fall initially to the new PCT clusters. At a time of major reorganisational transition it will be especially important to have in place adequate performance measures supported by transparent and robust mechanisms, through which the GP consortia and PCT clusters can account to local people for the quality and performance of local health services. I do not see how this can be achieved when PCTs are being decimated either by the efficiency cuts or people jumping ship to work elsewhere. Perhaps the Minister can say how he thinks this will be achieved.
We know that PCTs are responsible for commissioning a range of primary, community, secondary and tertiary health services, often in partnership with local authorities—for instance, in mental health—and, indeed, other PCTs, through networks or consortia for specialised services, and primary care clinicians through practice-based commissioning. That has already been mentioned by the noble Lord, Lord Patel—cancer networks being one of these. This is a complex landscape and it is about to become even more so. It will grow a whole new bureaucracy of its own if the competition which the Government intend to put at the heart of the Bill, whatever one believes about that, is as envisaged.
The majority of concerns with the health Bill in relation to commissioning of services fall into five broad areas: multidisciplinary commissioning; commissioning of long-term conditions; specialist commissioning; a lack of national guidance leading to fragmentation; and communication and co-ordination between providers and commissioners. A theme that runs throughout these areas is concern about the involvement of GPs and the ability of relevant commissioners to secure appropriate clinical input when commissioning services.
The King’s Fund report of the beginning of March highlights the need for strong, strategic commissioning to reconfigure some services such as cancer, cardiac and stroke care across large geographical areas. It argues that this will not be delivered by the Government's health reforms, which will abolish the strategic health authorities currently responsible for leading this work and leave GP consortia to fill the gap, which they are unlikely to be able to fill—to which I add that that will probably be the case for at least 10 years or so.
Briefly, on long-term and specialist conditions, throughout the debates since last July various advocates and campaigning organisations on almost every long-term condition have commented on the proposed reform. The Minster must accept that the Alzheimer’s Society, the cancer campaigns, diabetes organisations and many others are very worried about the commissioning for their conditions becoming fragmented and incoherent, to say nothing of end-of-life care and, for example, treatment for children with very serious conditions.
The Government are asking those who have fought long and hard for recognition of and improvement in the treatment and care of people to take on trust that everything will be okay. The Minister needs to accept that this clamour about commissioning, although we are joining it, is not motivated by Her Majesty’s Opposition being oppositionist; it is about a long list of concerns, questions and anxieties that we have to address without the proposed revolution. I look forward to the Minister’s reply.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I begin by thanking the noble Lord, Lord Turnberg, for tabling a Motion which has occasioned such a fascinating and often moving debate. As has happened previously, the breadth and depth of the contributions create their own problem in that, when there is such a short time available for me to reply, I am up against the clock. To the extent that I am unable to answer specific questions today, I apologise but I will of course happily follow them up in writing.
There are many reasons why we believe it is necessary to modernise the National Health Service. With rising costs of new treatments, an ageing population and rising public expectations, the system is simply not sustainable in its present form. Most importantly, however, the NHS must modernise in order to focus relentlessly on what matters most to patients: improving health outcomes. In so many ways it is a wonderful service, but we know that it can do better and we believe that it must do better. For our ambition is not limited to maintaining the current quality of services, it is far greater—to have health outcomes that are consistently among the very best in the world. I suggest to the noble Baroness, Lady Thornton, who said that now was not the time to do any of this, that the financial situation that we face provides even more of a reason to modernise swiftly. I hope that she and other noble Lords will agree with me that this debate is really about quality.
The noble Lord, Lord Turnberg, began by raising the Parliamentary and Health Service Ombudsman’s report, Care and Compassion? I am sure that all of us can identify with the concerns that he raised about nurse training and accountability for what happens on the hospital ward. I am sure I was not alone in being very moved by the noble Lord’s speech. I fully intend that we should learn from the ombudsman’s report, which is why its findings have been highlighted to NHS boards and why the Care Quality Commission will be commencing unannounced inspection visits shortly. However, I also submit that the changes that we are making to the NHS—placing the patient at the heart of everything we do—will help to guard against this happening in the future.
As the noble Lord, Lord Warner, rightly reminded us, effective commissioning is a key piece of the jigsaw. Currently, commissioning decisions are taken by primary care trusts—remote organisations that frankly few people have heard of and fewer still understand. We propose to hand responsibility for commissioning to GP-led consortia. Why are we doing so? It is because GPs and their clinical colleagues are the people who best understand the health needs of their local populations, and, in partnership with healthcare professionals from across primary, community and secondary care, they are ideally placed to design clinical services that provide more effective, integrated and preventive care.
Lord Davies of Stamford
I am very grateful to the Minister for giving way. Will the present system of “choose and book”, which seems to me to be working extremely well, be perpetuated under the new commissioning consortia regime?
Earl Howe
Yes, my Lords. However, if the noble Lord will forgive me, I do not propose to take many interventions as the time is limited. As I say, the answer to his question is yes.
Those who question the effectiveness of these arrangements should focus on the new framework of accountability that we are proposing as it is central. The new NHS will be more directly accountable than it is now. Because of that our reforms introduce a stronger national framework for driving quality improvement than ever before. How will this accountability work? The Secretary of State will hold the NHS Commissioning Board to account for delivery against the NHS outcomes framework, published in December. The NHS Commissioning Board will then hold individual consortia to account for their performance against the indicators set out in the more locally focused commissioning outcomes framework. There was widespread and strong support for such a framework during our consultation.
The NHS Commissioning Board will decide on the shape and content of the commissioning outcomes framework over the next two years, working closely with emerging consortia and with professional and patient groups. To help maintain momentum, the department will shortly publish a discussion document, seeking more detailed views on possible features of the framework. The Health and Social Care Bill contains a new duty of quality. The NHS Commissioning Board and GP consortia will be required continually to improve the quality of NHS services. Underpinning that, the Care Quality Commission will regulate providers on safety and quality, with wide-ranging enforcement powers to protect patients should providers fail to meet requirements. Accountability works in its fullest sense only if there is transparency. We will publish clear, easy to understand information on the quality of healthcare services and the progress being made to reduce health inequalities. We also propose, subject to the passage of the Bill, that the NHS Commissioning Board be able to make payments to consortia in recognition of the outcomes they achieve collaboratively through commissioning and the effectiveness with which they manage their financial resources.
How will quality be driven through the commissioning system? Quality standards, prepared by NICE, will be at the centre of it. Quality standards bring clarity to quality, providing definitive and authoritative statements of high-quality care, based on evidence of what works best. Quality of care does not cover just the effectiveness of that care but also includes patient safety and patient experience. The three domains of quality are interconnected: they cannot exist in isolation. The Royal College of Physicians reflected on this point in its response to the consultation on the NHS outcomes framework and acknowledged that healthcare that is not safe could not be described as efficient, effective or sustainable.
Our reforms will allow a re-established NICE to produce a broad library of quality standards that will cover the majority of NHS services. NICE will also develop quality standards for social care and public health. The Secretary of State and the NHS Commissioning Board will be able to commission quality standards jointly, which will open up the opportunity for standards to cover the whole care pathway, from public health interventions in primary care through to rehabilitation and long-term support in social care, and will support the integration of health and social care services. It is important to understand that quality standards will do more than just bring clarity to quality: they will have real traction within the system, underpinning the duty of quality and linking with the new best practice tariffs that will see providers paid more for better care.
GP consortia will have a duty to support the NHS Commissioning Board in continuously improving the quality of primary medical care services. That does not alter the board's overarching responsibility for commissioning GP services and holding GP contracts. But it does mean that consortia will play a systematic role in helping to monitor, benchmark and improve the quality of GP services, including through clinical governance and clinical audit. It means also that consortia will have a core role in improving patient care across the system. That will include both the quality and accessibility of the care that GP practices provide and the wider services that consortia commission on behalf of patients.
Where does the Secretary of State sit in all this? The Health and Social Care Bill strengthens the accountability of the Secretary of State to Parliament for the provision of the comprehensive health service. For the first time, the Secretary of State will have to report each year on the performance of the health service, consult on the annual objectives set for the NHS through a mandate, and lay both documents before Parliament. The NHS Commissioning Board will be accountable to the Secretary of State for delivering against that mandate.
Nursing has been a strong theme in the debate. The noble Baroness, Lady Emerton, asked when the Government's response to the report of the commission on nursing will be published. I can assure her that the Government will respond soon to the commission's report and I apologise for not having given her an undertaking to that effect sooner. The noble Lord, Lord Turnberg, and the noble Lord, Lord Winston, raised concerns about nursing standards in hospitals. As they know, we now have matrons in post. They have a specific remit for quality of patient experience and should be accessible to patients and carers. Matrons are directly accountable to directors of nursing, who should present ward-to-board reports. We launched the Principles of Nursing Practice in November last year. This sets out an agreed set of standards and behaviours that were developed by the Royal College of Nursing in association with patient groups. These principles reinforce the NHS constitution.
The noble Lord, Lord Turnberg, asked about the duty of consortia to improve the quality of care for older people. There is no specific duty in the Bill relating to consortia and older people. However, we propose a new duty for consortia to seek continuous improvements in the quality of services for patients and in outcomes, with particular regard to clinical effectiveness, safety and patient experience. That extends to all aspects of care.
The noble Baroness, Lady Sherlock, spoke about the recent King's Fund report. The report highlights particular variation in relation to patient involvement in decision-making, and in co-ordination and continuity of care. It also highlights the need for changes in leadership and culture. We have a strong system of general practice in this country, but we agree absolutely with the report that there is too much variation in quality. This reinforces the case for GP decommissioning, because one of the key aims behind the development of GP commissioning is for consortia to play a central role in helping to reduce variation and drive up the quality of general practice. There will be strong incentives for GP consortia to want to tackle these variations, because with lower-quality primary care one achieves poorer outcomes for patients and one has greater pressure on more expensive secondary care services.
The noble Baroness, Lady Sherlock, questioned whether the Government were allowing enough time to see whether the changes would work. With the introduction of shadow bodies and early implementers, we are allowing almost three years to consult, to dry-run and to put our reforms into practice on the ground, so that by 2013 the new organisations will have had time to secure capability collectively. Therefore, it is wrong to say that the house is being demolished; in many senses, we are refashioning some parts of the existing edifice.
On that theme, the noble Baroness, Lady Pitkeathley, asked how consortia will be authorised, given their different states of readiness. The pathfinder programme is, I think, central to sharing learning across emerging consortia, and it is a crucial part of their development to take on full commissioning responsibilities. Consortia will not have statutory responsibility for commissioning until April 2013, so the intervening period will allow all consortia to be ready by that time.
We listened to an impassioned speech from the noble Lord, Lord Owen, who criticised the Health and Social Care Bill on a number of fronts. Time prevents me setting out a detailed set of counterarguments but perhaps I may just say to him that we have tabled amendments to the Bill that will put beyond doubt that competition will be on the basis of quality and not price. Far from challenging the principles of the NHS, we have consistently made it clear that we are absolutely committed to a comprehensive National Health Service which is free at the point of use and is based on need rather than ability to pay. Nothing in our plans changes that.
The noble Lord criticised the policy of “any willing provider”, or “any qualified provider” as we are now calling it, because we think that that is a better description of the policy. The noble Baroness, Lady Thornton, did the same. “Any qualified provider” is about empowering patients and carers, improving their outcomes and experience, enabling innovation, and freeing up clinicians to drive change and improve practice. Introducing a choice of any qualified provider will give patients more control. That is what all the research evidence tells us they want and increasingly expect from the NHS. Why should not someone with MS be able to choose the physiotherapist they want and be treated at the time and in the setting that best suits their need? Why should not a patient, at the end of their life, choose their hospice provider? Patients are already able to choose from any provider that meets NHS standards and prices when they are referred for a first out-patient appointment to a consultant-led team. That was an innovation brought in by the previous Government. “Any qualified provider” will extend that principle to more providers and more services, including social enterprises and charities, particularly in community care. For the life of me, I cannot see what is wrong with that. Money will follow the patient and the choices they make about where and by whom they are treated.
The noble Lord, Lord Owen, indicated his belief that the policies that the Government are advancing will damage clinical professionalism and remove the intimacy inherent in the doctor/patient relationship. I say to the noble Lord gently and with huge respect that I do not believe he has any basis whatever for suggesting that. I would argue, on the contrary, that clinically-led commissioning brings the design of services closer to patients.
Earl Howe
The department has sought legal advice on that point and the strong consensus is that the NHS, as we envisage it initially, will not be subject to EU competition law. It is not at the moment, as the noble Lord will know, although of course the situation can change over time. This is an interesting, and rather esoteric, area of debate but I do not think that it impacts—
Earl Howe
I mean that it becomes rather technical. However, I do not think that it impacts on the central point that I was seeking to make, which was to argue that the noble Lord’s contention that the doctor/patient relationship would be damaged does not stand up. To me, the principle of shared decision-making—“no decision about me without me”—will bring about an even closer partnership between clinicians and patients.
The noble Lord, Lord Patel, spoke about cancer services. GP consortia will be well placed to commission the majority of cancer services and GPs have a crucial role to play to achieve earlier diagnosis of cancer. As a first step in relation to cancer services, we will work with GP consortia and pathfinders to identify and provide the sort of data that they will find useful to commission cancer services effectively. We will provide GP consortia profiles of services and outcomes for their local populations—for example, cancer survival rates, the use of the two-week urgent referral pathway, uptake of screening and use of inpatient beds. We will be benchmarking the data against similar consortia so that they will know what needs tackling to improve outcomes in their areas. However, as the noble Lord will know, we have also earmarked a great deal of money to ensure that our plans for earlier diagnosis—giving GPs direct access to key diagnostic tests, for example—will assist in the process. He asked about cancer networks. They have had a crucial role in improving the quality of cancer treatment. I quite agree with him. They have helped commissioners, providers and patients to work together to plan and deliver high-quality cancer services. GP consortia will need commissioning support and cancer networks will be well placed to provide that. The department has said that next year there will be funding for cancer networks to support commissioning.
The noble Lord, Lord Touhig, asked about the commissioning of autism services. The health and well-being board will be the key vehicle by which commissioners and local authorities can work together, ensuring that services that cross health and social care can be effectively commissioned. The noble Lord raised a number of valid points about how these arrangements for autism services will work in practice. I suggest that I cover those in a detailed letter.
The noble Baroness, Lady Hollins, and my noble friend Lady Tyler questioned the ability of consortia to commission mental health. We recognise the need for GP commissioners to collaborate with their clinical colleagues and one of the key initiatives in mental health derives from the new joint commissioning panels set up in partnership between the Royal College of Psychiatrists, the Royal College of General Practitioners, the Association of Directors of Adult Social Services, and others. That collaboration works to promote integrated working across secondary and social care. The outcomes and lessons from this work will be made available to inform the implementation of the new commissioning arrangements.
My noble friend Lady Benjamin asked a number of questions about sickle cell. Again, I should like, if I may, to take full advice from my department about the points she raised and write to her.
Our reforms are ambitious and challenging but we have been heartened by the enthusiasm that we have found among clinicians, especially among those already taking increasing levels of responsibility through the new consortia. There are now 177 GP pathfinders involving more than 5,000 GP practices, covering more than 35 million people across England. I am confident that by empowering clinicians to innovate and deliver health services we can continue to address the healthcare needs of this country and move towards delivering outcomes that are indeed consistently among the best in the world.
Lord Turnberg
My Lords, this has been a fascinating debate and I am enormously grateful to noble Lords for many outstanding speeches. I have learnt a lot. I am only sorry that we had such a short time—each speaker had only four minutes—but I am constantly amazed at how noble Lords are able to pack in so much useful information in such a short time. The noble Earl, as one might expect, was eloquent and convincing, but it remains to be seen how many he has convinced around the House. I am sure that he is as aware as I am that these are not the last words we will hear on these matters. With those few comments, I beg leave to withdraw the Motion.