NHS: Standards of Care and Commissioning

Lord Alderdice Excerpts

Thursday 31st March 2011 Lords Chamber

[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.