Health: Spending Cuts

Baroness Finlay of Llandaff Excerpts

Wednesday 30th June 2010 Lords Chamber

[Earl Howe]

My Lords, as I have just indicated, the Department of Health is very fortunate to be protected from cuts in its budget during this Parliament, but at the same time we have a duty to spend every pound wisely and to obtain value for money. The spending review is still ahead of us. The only cuts that I can predict are those to bureaucracy and administration, to enable us to direct more money into front-line healthcare.

[Baroness Finlay of Llandaff]

Will the Minister provide an assurance to those highly specialised secondary care services that are fearful that GP commissioning may be at too small a population level to ensure that those with complex conditions, which may need complex early diagnosis and management, will be adequately managed? I declare an interest as a member of the BMA ARM at the moment.

[Earl Howe]

My Lords, the noble Baroness is right to draw attention to this issue, of which I am very conscious. Where we have commissioning, it is important that the population base for a given condition is sufficient for that commissioning organisation to contend with. With regard to specialised conditions, I am working hard to ensure that the model we propose will take them fully into account.

Health: Primary and Community Care

Baroness Finlay of Llandaff Excerpts

Thursday 24th June 2010 Lords Chamber

[Baroness Finlay of Llandaff]

My Lords, I must declare an interest as a true Dr Finlay. I am a practising clinician; I am president of the Chartered Society of Physiotherapy; I work in palliative medicine; and I have links with many hospices around the UK. I hope that I have made all the declarations before I start.

We are facing change and I am sure that the Minister is inundated with advice and pressures but in the time preceding change, I hope that he will be cautious so that we do not have change while ignoring the potential unintended consequences of such change. One of the difficulties is that often we do not know what we do not know, and in the rush to bring about change we may not do the background research or explore the issues. I want to address the specialist services providing care for patients, the role of the third sector, particularly for terminal and palliative care, and the needs of patients out of hours.

In 2006, in England and Wales there were 503,000 deaths. That figure is anticipated to rise to 586,000 in 2030, which is a massive increase. Only about 20 per cent of patients die at home, so we have to think how the needs of all these patients will be accommodated. With that there has been pressure to move patients out into the community. The need for integrated care pathways for complex conditions increases as high levels of expertise are required to meet patient needs and there are more patients with complex conditions. I am concerned that in trying to save money substitution has been looked at but it is not without its dangers.

Despite a priority of providing care closer to home, the Audit Commission report, More for Less, found little evidence to show that PCTs have been successful in removing care from hospitals. There is little evidence that patients with rare, complex conditions are not prepared to travel to get expert care, because they know that they need accurate diagnosis and a really good management plan. The challenge is: how do we get patients seen by the right person at the right time in the right setting, as well as trying to move care out into the community? That is a stark cultural challenge that needs multiprofessional teams working in managed clinical networks to encourage collaboration and co-operation between primary, community and secondary care. That must also cover other aspects of home care provision, including social care.

The new commissioning arrangements must cross traditional NHS boundaries. The publication by the Royal Colleges of Physicians and General Practitioners, Teams without Walls, identified the need for integrated systems, clinical leadership in commissioning and aligned incentives, underpinned by patient involvement in commissioning systems, especially for those with long-term conditions.

The current problem is that payment-by-results tariffs in their present form incentivise against integrated care. The current tariff-based system encourages hospitals to treat more patients while, simultaneously, GPs are under pressure to refer fewer patients. That creates a tension that can work against the development of integration and against quality in patient care. It works against earlier diagnosis, particularly in recognising rarer and complex conditions. One way to rebalance the disincentive is to introduce payment by pathways or payment by conditions, to ensure that high quality generalist and specialist care have a sustainable future, for the benefit of patients.

Patients must enjoy equitable access to specialists when required. I have just chaired a joint report on allergies for the Royal Colleges of Physicians and Pathologists, and we have found a stark inequity in provision around the country. Specialist resources must be at the heart of any clinical network or community-based service. It is essential that we have services available 24/7. The current five-day provision does not meet patient needs. That service does not respond to the true, seven-day need of those who are really ill, including at night. In Wales, we have moved from five-day to seven-day working by clinical nurse specialists in palliative care, and we have shown in a short space of time a dramatic change, because problems that occur on Saturday will be dealt with on the Saturday or Sunday. By the Monday, it would have been too late to address them.

There are some specialist service needs where integration is essential. There needs to be a one-to-one relationship between the GP, the patient and the specialist in secondary care to ensure patient safety and that people understand the complexity of the patient's background. Repeated handovers do not work well. We know that information is being lost in a kind of conveyor-belt hand-over between clinicians. We need to restore patient safety and quality of care and ensure that the lead clinician has a comprehensive understanding of the patient to reduce complications and near misses, particularly in surgery.

Some things should be done only in places well equipped to do them. An increasing amount of so-called minor surgery has been done in general practice, but there have been some awful situations where melanomas have been removed, the margins have not been adequately marked, the resection was inadequate and the subsequent surgery was much more extensive and expensive than if it had been done in a specialist dermatology surgery centre at the outset. The Anaphylaxis Campaign has sent me horror stories of GPs giving advice to parents about children suspected of having a peanut allergy that was completely inappropriate and would have jeopardised the child’s life, not just their health. It was just as well that the parents phoned the campaign with their anxiety.

There are real problems out there, and there are risks as well as opportunities in moving towards a largely GP-commissioned framework. Academic GP is essential to driving up the standard of evaluation. We need to evaluate patient outcomes in any change. This is not about having a fashion for one model or another; an evidence base must underpin commissioning. As PCTs are divested of their commissioning responsibilities, GP consortia are expected to take up the mantle, but their skills and background knowledge, and even their willingness to do this, are really deficient in some places.

There needs to be a national view on minimum access rates and the provision of highly expert services to avoid a postcode lottery, particularly where there is a low critical mass in a smaller population, otherwise you get a bidding war between GPs and consultants that works against quality. If you do not have adequate dual provision, community-based services will have fewer places to turn to for training specialists for the future, for continuing professional development and for research. Driving that forwards will drive up standards of care in the future, particularly for those with more complex conditions.

I ask the Minister to consider some specific things: that promoting the idea that engaging doctors in the spirit of collaboration is required for successful commissioning; that commercial loss leaders might appear at first sight to be useful but may lose expertise and undermine quality in the long term; that the repudiation of unhealthy forms of competition is essential, as is encouraging jointly commissioned models for integrated health services; that choice for patients means the ability to access specialist scientifically based clinical excellence to diagnose and plan their management, which can then go back for ongoing care in primary care if there are good pathways; and, lastly, that the incentives and disincentives of payments by result need to be rebalanced to bring integrated generalists and specialist care closer to the patient’s home.

I am grateful to the noble Lord, Lord Alderdice, for flagging up the importance of the whole person and the whole family, because the third sector provides that par excellence in hospice care. There is a need to specify minimum levels of service, such as in hospice care, across the UK, and to have centrally agreed three-year contract with an agreement on how the service is delivered locally. At the moment, Marie Curie has to negotiate 200 separate contracts across the UK. That is a waste of time and a duplication of effort when models such as the fire service or the police demonstrate that you could have a national framework with local agreements on implementation.

Hospice grant money has to be negotiated at a local level by small hospices that often do not have much expertise in negotiating with all the different people from whom their patients come. Competitive tendering is punitive to the third sector, because it does not have the resources to tender or the expertise of larger bodies. Punitive contracts in the third sector can really work against them. If they miss a level in their service they may incur a penalty, yet they provide a key service to the NHS.

Commissioning must become outcome-related, as much in hospice care as anywhere else. Currently, it seems to be process-related. It has to be integrated across the whole pathway, and this need to commission across the whole pathway means that the professional competency framework needs to be driven up to promote higher levels of competency. There is a real concern and a danger that private companies will come in and commission against a whole pathway, and one questions why they are needed as an intermediary. The danger is that increased income will go in profits to shareholders and not be reinvested in the not-for-profit third sector that the hospices epitomise.

In summary, there needs to be 24/7 provision, which should be addressed urgently. There is a large shortfall in district nursing. Only 53 per cent of PCTs have 24-hour district nursing, which is grossly inadequate if you are trying to care for critically ill patients at home. There has to be a closer link between health and social care. Care assistants can often be the key people to keeping patients at home.

On incentives, we should remember that healthcare professionals are proud. They want to deliver a good service. If you embed direct patient feedback into the system, as we have in Wales for palliative care using iWantGreatCare, it can become a powerful driver to quality improvement. One team does not want to perform less well than another, but patients need to provide feedback in an anonymised way so that they are not fearful that their comments might antagonise the clinicians looking after them.

There have been unintended outcomes from the current arrangements where financial incentives or punishments drive provision rather than need. Patients feel particularly lost out of hours and it is really important in commissioning healthcare that we get it right. There is a steady stream of horror stories coming through. It is not simple; it is not like shopping for shoes; and I hope that the Minister will think carefully about the unintended consequences of change.

Mid Staffordshire NHS Foundation Trust

Baroness Finlay of Llandaff Excerpts

Wednesday 9th June 2010 Lords Chamber

[Earl Howe]

My Lords, I agree wholeheartedly with my noble friend that in many parts of the NHS we need a culture change—a culture that puts patients first. We need an NHS that listens to patients and responds to their concerns and needs. We must prioritise the people whom the NHS serves and we must listen to the doctors and nurses who work in it. The measures that we are taking today on whistleblowing are important. Last week, we began to publish more transparent data about the NHS so that people can hold their local services to account in a more meaningful way. We are looking also at reducing the number of hospital readmissions, as I am sure my noble friend is aware.

The culture change that is needed will not happen in a hurry and I would not want to give the impression that it is required everywhere in the NHS. Mid Staffordshire was an unusual event, but unless we get to the bottom of why it happened there must be a fear that it may happen again. As we move forward and propose to Parliament changes in the way in which the NHS is regulated and care is commissioned, we must not lay ourselves open to unintended traps. I therefore concur with all that my noble friend said. I think that he will find, as we bring forward our proposals, that the emphasis on transparency, openness and the patient’s voice will do much to address the concerns raised.

[Baroness Finlay of Llandaff]

My Lords, the Minister has spoken about listening to professionals and to patients. Will he give an undertaking that, long before whistleblowing is necessary, there really will be measures in place to support staff who want to raise concerns that changes proposed by management might adversely affect patient outcomes? That requires an empowering of clinicians at the coal face.

Furthermore, as the Government consider changes in the NHS generally, will they not be fooled into thinking that this was a completely isolated event? I fear that there are a lot of other pockets in the NHS that are not right. What emerged from the inquiry were the voices of the patients’ relatives. When they gave evidence, those voices shouted out loud and clear that things were wrong, but they were not adequately heard. I commend—I declare an interest here—the Dying Well Matters programme as part of the Wales 1000 Lives Campaign, which I have been involved in instigating. It routinely seeks stories from relatives and patients before trouble occurs to try to detect those subtle but extremely distressing instances of poor and inadequate care in parts of the service that otherwise might go unnoticed.

[Earl Howe]

My Lords, as ever, the House will listen to the noble Baroness with great attention and respect, knowing that she works in the midst of an important and active part of the NHS. I hope that she is wrong and that the seriousness of the malpractice at Mid Staffordshire is rare, but we have to be vigilant. There could be another instance of a failing trust out there. The House may want to know that the Care Quality Commission has announced the registration status of 378 NHS trusts to provide healthcare services from 1 April. Only 22 of those are registered with conditions, but the CQC has said that those trusts are safe to provide services to patients. No trusts were refused registration, which is an important point.

On the question of openness within trusts, the noble Baroness is right: a culture of openness and willingness to learn from mistakes is essential to a health service that wishes to improve. There is a requirement on hospitals to inform regulators about serious errors, but that requirement does not extend to informing patients, so we are looking at how that can be addressed.

Genomic Medicine: S&T Committee Report

Baroness Finlay of Llandaff Excerpts

Wednesday 9th June 2010 Lords Chamber

[Baroness Finlay of Llandaff]

My Lords, I was fortunate enough to be co-opted on to the inquiry and it has been a great privilege to work alongside so many people from a scientific background, many of whom sit on our Cross Benches. I congratulate my noble friend Lord Patel on his chairing of the committee and on his splendid introduction today.

I wish to speak about stratified or personalised medicine, the area of genomic medicine predicted to hold great potential for healthcare in the near term. It entails matching treatments to specific patients using clinical biomarkers to target treatments effectively by taking account of patient susceptibility to particular drugs or to adverse drug reactions. The Royal College of Pathologists told us that it anticipates that DNA and RNA-based diagnostic approaches,

“will guide more appropriate treatment and avoid ineffective treatment, and will identify some patients who do not need treatment. [They] will be an absolute requirement before the administration of many new treatments, especially new anti-cancer drugs; [and] will increasingly allow the prior prediction of severe adverse [drug] reactions”.

However, doing the test is not enough; it is the clinical context that is crucial. Therefore any thoughts that over-the-counter tests could move things out of the clinical arena are misplaced. Tests can be misleading at best—but they can be worse than that if they are not conducted in a proper clinical context.

My noble friend Lord Patel has already spoken about the cancer treatments that have emerged indicating a likelihood of a response to drugs, particularly Herceptin and Iressa in breast and lung cancer respectively. It is worth noting that such testing has increased about threefold in the past two years.

However, there are problems surrounding, in general, the translation of research on pharmacogenetic tests into applications. At present there is little incentive for the pharmaceutical industry to develop the genomic tests because the business model relies on the consumption of a product—a rather blockbuster approach—to ensure a return on the substantial R&D investment which is needed to bring a drug to the market. However, stratified medicine targets a much smaller patient group and requires the development of accompanying tests, and these tests must be developed in parallel with the therapy itself.

Professor Sir John Bell suggested that,

“the delivery of a new set of genetic tools into the clinic has proved really difficult”.

One reason for this was that diagnostic companies could not be relied on,

“to do what is done in therapeutics, which is to demonstrate clinical utility”.

This was because,

“the cost of a clinical utility programme is such that, at the prices paid for diagnostics, they would never get the money back”.

We therefore recommended flexible pricing models for therapies that rely on the use of pharmacogenetic tests, the protection of intellectual property and the concurrent development and authorisation processes for therapies and diagnostic tests that will assess the clinical utility and validity of genetic and genomic tests within the NHS.

The previous Government’s response stated that the Department of Health had commissioned NICE to develop and manage a single evaluation pathway specifically for diagnostic technologies, with a pilot scheme due to report this summer. A new committee within NICE should ensure health technology assessments look at the clinical utility and validity of diagnostic tests. Can the Minister assure us that these developments are still on course? Can he clarify how the proposed value-based pricing system will allow targeted treatments to be more available, even if at a local level commissioning decisions do not support the necessary infrastructure? There may be a potential tension here between central promises and local sovereignty in decision-making.

This is particularly important when evaluating diagnostic tests. These are inherently more complex to evaluate and yet the funds for doing so are relatively trivial. Commissioners do not know when to invest in expensive testing equipment if its utility and validity has not been assessed, and so silo budgeting acts as a barrier to capital investments, leading to a postcode lottery in diagnostics. Decisions need to be made at a national strategic level, not locally, and it is essential that clinical genetics departments are supported. They should be linked and pivotal to informing studies into the whole commissioning process. Can the Minister confirm that the Department for Business, Innovation and Skills is working with the Department of Health to ensure that intellectual property systems and management of intellectual property rights support diagnostic test development, evaluation and rollout as we recommended?

The research community is collaborating to realise the potential of the NHS for the benefit of all. The network of hospitals in the NHS is ideally placed to link with research bodies. Indeed, the funding bodies are doing just that. This year Cancer Research UK will begin to establish a network of NHS centres using similar genetic techniques to guide treatment decisions. It will be the precursor to treating every NHS cancer patient in a similar way, perhaps in as little as five years. However, other genetic tests have not been integrated properly into healthcare. Our committee heard of the patchiness of testing, as has already been alluded to, for conditions such as diabetes.

There is a lack of clarity over funding streams for the use of such tests as part of treatments within non-genetic specialties, and there are inconsistencies in the ordering of such tests during consultations. As I have said, doing the test alone is not enough; it is the clinical context that is key. Genetic testing is usually in the genetics department’s budget and so is not necessarily more widely available. The cost of testing is increased if the patient has to be referred to be seen in genetics rather than a treating clinician taking responsibility for the whole process. Meanwhile, genetics departments are increasingly taken up with the delineation of single gene disorders as a subset of common complex disorders, and with the co-ordination of care for those with single gene, multi-system complex disease. Genetics departments are already facing potential overload.

To ensure better use of drugs we need a red flag system of automated warnings rolled out to ensure that appropriate tests happen routinely. This will result in a cost saving through stopping inappropriate prescribing and inappropriate testing and avoid adverse reactions.

The area that concerns me most of all is the failure of the Human Tissue Act to promote single gene testing for single gene sudden death disorders that mean that many young lives are lost. For more than 20 years we have been able to perform gene testing in the family and make an early diagnosis in the family of a risk of sudden cardiac death. NICE recommended the testing but at a clinical level it is not readily available.

One problem is that there is no clear definition at post-mortem of “retention” for tissue samples, so, whether or not anything is seen macroscopically, samples are not always sent for DNA testing. If the family is not integrally linked into the process, samples can fall between pathology, genetics and the coroners system, and a diagnostic opportunity for others in the family can be lost. Will the Minister assure me that we will look urgently at this matter so that all patients who die of suspected sudden cardiac death will have tissue removed post-mortem for comprehensive DNA analysis? That will be linked to genetic support. Such testing should be for multiple genes, because it will save lives.

The UK Genetic Testing Network is meant to be undertaking a review of service provision within the NHS to inform a consistent approach for single-gene disorders and single-gene subtypes of common disorders. Does the Minister know when we can expect the Government's comprehensive assessment of this? I realise that it is difficult for a Government who have only just taken over something already in progress.

An extension of genomic medicine is epigenetics; that is, changes in the gene expression caused by mechanisms other than a change in the underlying DNA. The molecular basis of these changes is related to the packaging proteins known collectively as chromatin. The changes are not encoded in the genome sequence so are not generally passed from generation to generation. We are seeing ever more examples of underlying genetic links, such as the link with addiction, where it seems that the serotonin and dopamine in the brain’s reward systems may be linked in some people when other factors come into play with developing addictions. However, it does not mean that everybody with that piece of genetic code will necessarily become an addict.

Understanding these developments provides a “fantastic window” on different types of common diseases, but genetic counselling and genetic support are key if we are going to use any advances appropriately. I must declare an interest: I am at Cardiff University, which has one of only two established MSc courses in genetic counselling in the UK. It is well on its way to becoming an independent discipline.

We need to ensure that genetic testing and services are supported today to ensure that developments are used to best advantage when they appear tomorrow.

Health: Dementia

Baroness Finlay of Llandaff Excerpts

Thursday 3rd June 2010 Lords Chamber

[Earl Howe]

My Lords, the Care Quality Commission is revising its current quality rating system for adult social care and is working closely with the adult social care sector to develop a more user-friendly system that provides people using services with the information they need to make decisions about their care. That is absolutely in tune with the work being done in the department on driving up quality standards in dementia care. Better information for people with dementia and their carers will enable individuals to have a good understanding of their local services, how they compare with other services and the level of quality that they can expect.

[Baroness Finlay of Llandaff]

My Lords, will the Government maintain the e-learning packages developed in palliative care to enhance end-of-life care for people with dementia across health and social care, and will they respect the agreement that those packages should be rolled out in Wales? I declare an interest as the palliative care lead for Wales.

[Earl Howe]

My Lords, it so happens that only yesterday I received a briefing on the e-learning programme, and I am well seized of the value attached to it by the royal colleges in particular as well as many other professional bodies.