Junior Doctors: Industrial Action

Lord Birt Excerpts

Monday 25th April 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, first, the need for a seven-day service has been recognised by the medical profession for a number of years. I remember reading the Future Hospital report four or five years ago in which the Royal College of Physicians talked about a seven-day service. Of course, it was the academy of the royal colleges that produced the 10 clinical standards that underpin a seven-day service. The issue is not whether or not there should be a seven-day service; the more serious issue that has been raised is whether we have the resources to deliver a seven-day service. We argue that we are putting enough resources into the NHS to do that. So I think that the principle of a seven-day service, certainly for urgent and emergency care, if not for elective care, is well accepted by the medical profession.

Interestingly, on the point about the number of people leaving—the resignations that the noble Lord referred to—I was pretty horrified to hear about the son of someone on the noble Lord’s Benches who had left the NHS to go to work in America two years ago, I think. He described a pretty torrid time working in the NHS as a junior doctor. To cap it all, when he went, there was no exit interview. No one was really concerned or knew that he had gone. That is just another illustration of the fact that we have not sufficiently respected or valued junior doctors in the NHS.

[Lord Birt (CB)]

My Lords, I wholly support the Government’s objective of seven-day working in every part, eventually, of the health service. However, I observe that the Government are trying to achieve these objectives, as the noble Lord, Lord Hunt, has just said, in a very economically adverse climate where health spend per head is in decline, in a country where the population is expanding very rapidly, and where we see significant bottlenecks right across the system. All of us can see how important junior doctors are to the system. I do not know how many of your Lordships saw the excellent BBC series on junior doctors a year or so ago set at the Royal Liverpool Hospital, in which their importance to the system and dedication was simply remarkable. We would all, I am sure, stand behind that. They should not be threatening to withdraw their labour, but it is amazing that a group of such dedicated workers can even consider doing such an inappropriate thing—they are not natural strikers. The question I put to the Minister is this: as I said, the Government’s objective is correct, but should they not move towards it with greater stealth in the context of moving towards a health service that is again appropriately funded?

[Lord Prior of Brampton]

My Lords, I echo the sentiments of the noble Lord. I recognise the vocational commitment of junior doctors and that they are not natural strikers. It is a tragedy that we have got into this situation. There are no winners in this dispute and only one absolutely clear loser: the thousands of patients who are now suffering. The noble Lord asked whether we could have got here with greater stealth. These discussions have been going on for three years. We have had one independent review done by the DDRB and a number of independent assessments of the impact on mortality of not working at weekends. The Government are putting £10 billion of new money into the health service over the next five years, which was asked for by the NHS. In the NHS there will always be a lack of resources: demand will always exceed supply in a system where there is no price mechanism. That is an issue that all Ministers have lived with in the NHS since 1948. However, I echo his views: it is tragic that we find ourselves in this position with junior doctors. They are not natural strikers.

Care Sector

Lord Birt Excerpts

Tuesday 25th November 2014 Lords Chamber

[Lord Birt (CB)]

My Lords, we are all grateful to the noble Baroness, Lady Kingsmill, for, in her words, shining a brighter light on this critical set of interlocking issues. I declare an interest as a business adviser to a fund that invests in care homes as well as in many other sectors.

The care of the elderly is an issue about which we all have strong feelings. Those have been expressed many times already. I shall not easily forget, just a small number of years ago, my own father’s last chaotic and distressing months tumbling from hospital to home, to care home, back to hospital, back again home and, finally, to a hospice. It was a journey for the most part marked by high standards of care but absent any trusted guide whatever. He was but a baton passed clumsily from hand to hand.

A fortnight ago, I spent a morning in a care home and was inspired—others have spoken of this—by the utter dedication and kindliness of the staff there, who meet the whole gamut of human and bodily needs over 24 hours a day, seven days a week. It truly is a challenging set of tasks. Some help patients who have severe dementia, while other patients are,

“sans teeth, sans eyes, sans taste, sans everything”.

Almost all those staff were immigrants to the UK. To echo the noble Baroness, Lady Brinton, and the noble Lord, Lord Lipsey, without these immigrants, whatever would we do? The care and nursing sectors in the UK face severe skill shortages. Major businesses are forced to recruit in huge numbers in the Philippines, Romania, India and other countries for the skills that the UK labour market is simply not supplying. Why cannot we manage our education and skills sector so that it produces skills—they are skills—on the scale that we need?

We would all agree that we want the highest standards in the care sector for our loved ones and finally, no doubt, ourselves. Yet we know from excellent investigative journalism—I am sure that we have all seen it and it is very painful—that standards are not always high. The CQC, quite rightly, is increasingly vigorous and rigorous and it is raising the bar. As a result, staff numbers are increasing and costs are rising. Were the Labour Party to assume office and raise the minimum wage, costs would rise higher still in the sector. Yet around two-thirds of those in care homes are funded by local authorities. Local authorities, as we have heard many times in this short debate, are themselves straitened and have been reducing not raising fees by some 5% in real terms over the past three years.

In the home that I visited—the noble Lord, Lord Lipsey, just made the same point—the local authority was paying fees significantly below the actual cost of providing the very services that it and we would expect. This simply cannot continue. It is not viable or sustainable as a policy. The great majority of care homes are privately owned. The returns for those investing in the sector are dangerously low. The whole system is in extreme financial tension and we lack sufficient incentives to ensure that provision will increase, as the noble Lord, Lord Lipsey, has just said, as need grows, which it will. There appears to be a policy vacuum. Whoever forms the next Government simply must provide a holistic policy and financial overview of the care challenge. That must involve the NHS. Everyone can see that unnecessarily filling a hospital bed is vastly more expensive than providing a place in an appropriate care home.

We need an overview from the Government of how best to provide effective, civilised, seamless care to those in the final stages of their lives, whether at home, in care or in hospital. We need appropriate structures—we do not have them—processes and incentives, a single point of responsibility at local level and the right governance in place to ensure that the system is working as it should and as we would all wish. Finally, we need not only to determine the proper balance between state and private funding but to be clear that, where the state accepts financial responsibility and rightly requires high standards, then in turn it must also will the means as well as the ends.

Health and Social Care Bill

Lord Birt Excerpts

Monday 19th March 2012 Lords Chamber

[Baroness Jay of Paddington]

My Lords, as the House knows, I chair your Lordships’ Constitution Committee, which has produced two reports on the Bill. As everyone has said, the Bill is enormously complicated and very detailed, and we have been very detailed in our consideration of it.

I support the amendment of the noble Lord, Lord Owen, because the noble Earl the Minister has, as we all know—and we have all paid due respect to him on this—been enormously helpful to the House’s consideration and the production of amendments. The Constitution Committee itself produced very important amendments on the Secretary of State’s role on this. All this has demonstrated the very sound, elaborate and good processes by which this House and its Select Committees, as well as the many experts, as the noble and learned Lord, Lord Mackay of Clashfern, has just mentioned, have contributed to the debate. We have proceeded on this in an extremely sensible, measured and considered way.

The Government have been very generous and the Minister has been particularly generous in accepting amendments and entering into discussion. Having listened to the noble Lord, Lord Owen, I think he is saying that the House should continue to follow the very good process that we have had in formulating our opinions on the Bill. We have taken time and have deliberated very carefully. The House has listened to many views, including those of its Select Committees and of its many expert Members. As the noble Lord, Lord Owen, said, we have also listened to many people outside.

Over the weekend, I have been particularly amazed at the last-minute contributions from, for example, the Royal College of Physicians. The noble Lord, Lord Owen, mentioned one online petition, and I have received another from the organisation Avaaz, signed by 110,000 people. The cumulative figures suggest that in the past few days more than 500,000 people have signed online petitions specifically relating to the amendment of the noble Lord, Lord Owen, not to the more general point.

I say to the House that we have followed the processes very well indeed in relation to this Bill. We have agreed to disagree on some things, and the Government have accepted amendments where they have accepted the arguments. In following the processes, which this House has created very successfully over the years, we have used our best efforts with regard to the Bill, and we can lose nothing by continuing to follow those processes and, finally, by taking note of the tribunal’s report, as the noble Lord, Lord Owen, has suggested.

[Lord Birt]

My Lords, I rise to underline some of the arguments articulated by the noble Lord, Lord Fowler. A risk register is a key prerequisite of any effective organisation, whether public or private. I have had experience of a variety of registers in both the public and private sectors. When I worked at No. 10, I was a member of the Cabinet Office Strategy Board, and one of the tasks of that board was to consider what was effectively the national risk register.

What is the purpose of a risk register? It is to identify all risks. Every risk register that I have ever looked at has been kept highly confidential because it has always been gory and hair-raising to read. The purpose of identifying worst-case risks is to do your best to prevent them and, if you do not prevent them, you need to work out, in advance, what you will do if bad things happen. To create an effective risk register, you need to—

[Baroness Thornton]

Is the noble Lord aware that all NHS organisations, strategic health authorities, PCTs and local authorities have risk registers and they publish them?

[Lord Birt]

I shall come to the risks of publication in a second. What are the means of creating an effective risk register? You need to involve those in governance and delivery and you need absolute candour and trust in the process. The consequence of making any risk register public is that it will be anodyne and the risks would simply cease to be managed, which is not in the public interest. I would hope that Governments of any persuasion would resist the notion of publishing any risk register. It is a matter of regret that one risk register in respect of Heathrow was published. It follows from that that I am unable to support the amendment.

[Lord Peston]

I support the noble Lord, Lord Owen, in what I regard as a special case. I think he, too, is arguing that this is a special case. As background, perhaps I may refer to my experience last week when I spent quite a long time at St Thomas’s Hospital, where I think the noble Lord, Lord Owen, was a most distinguished graduate. I was an NHS patient and my experience was of a service working exceptionally well medically, not wasting resources, and staffed by people devoted to the care of patients. Those to whom I spoke told me that that was why they had entered the medical profession; they wanted to work in hospitals. In other words, my experience was diametrically opposed to the basis on which this whole Bill is put forward by the Secretary of State, who constantly attacks the NHS, constantly argues that it wastes resources and constantly argues that it needs private sector involvement in order to make it work properly.

The reason for wishing to see the risk register, which I regard as fundamental in this case, is to ask the question: was the Secretary of State warned of this? Did anyone place before him the information and the argument that his account of the NHS does not correspond to reality as experienced by those of us who use it? That is why it seems to me that the noble Lord, Lord Owen, is asking to see the documentation. Those of us who have advised Governments are perfectly well aware that Ministers have many different views put before them. We are perfectly well aware that civil servants have their own agendas and there is nothing surprising about that. Equally, those of us who have advised Governments know that all decision-making involves risks, so to try to pretend that there is no risk and that there is a case for keeping it secret seems preposterous.

Last week, we heard the approach of those who are still dyed-in-the-wool opponents of anything appearing in the public domain. I hate to say it but such people were involved with our own Government not that long ago, although I thought that we had abandoned those days and that openness had become our touchstone. Last week, I said to the Minister that when I gave advice, I would have been insulted at the suggestion that I did not say to a Minister what I actually thought and, if I were told that what I had said was in the public domain and asked to tone down my remarks that what they were thinking of was stupid, I would not have done so. Addressing the Minister directly, I add that the 30-year rule has given some of us considerable embarrassment. Some of the things I said in the past turned out to be absolute balderdash but I can live with that because it is what I thought at the time. It turns out that I was wrong.

The path that the noble Lord, Lord Owen, wants to take us down is, as a special case, precisely the correct one. I do not think it will destroy our Civil Service; it will not cause honest men and women suddenly to start telling lies in order to ingratiate themselves with the Minister. I am absolutely certain this is a special case which your Lordships should espouse.

Health and Social Care Bill

Lord Birt Excerpts

Tuesday 11th October 2011 Lords Chamber

[Lord Birt]

My Lords, there is probably no one in your Lordships’ House who does not have cause to be grateful for what the NHS has done for them or their families. Recently, as my own parents entered the final chapter of their long lives, I witnessed at close hand the expertise, dedication and sheer good cheer of the care that they were fortunate enough to receive.

However, I also saw the many ways in which the NHS could improve. That is no surprise. All organisations can improve. All need to adapt and develop in the light of the continuously shifting circumstances they encounter. Technology will offer radical opportunities for improving effectiveness and efficiency. Science will uncover previously unthought-of ways of addressing old problems. Citizens and consumers will make new and different demands. The private sector offers examples of organisations of every size that have transformed their effectiveness, often at times of great adversity. They have had to develop new capabilities, to create new structures or, to define a new focus or accountability.

The test of all health reform is: will the proposal create better health outcomes? Can the UK match or improve on best international practice? Will the reform enhance patient choice, experience and convenience? Will GP surgeries be encouraged to be open when a population largely in work is most free to visit, furthermore relieving an unnecessary burden on A&E? Will the reform promote efficiency, and thus optimise the health outcomes for any given level of available resource? Will it foster and reward innovation? Will it enable a diversity of providers, competing on quality, on clinical effectiveness, and on patient satisfaction, as well as efficiency of provision? As treatment possibilities change, will the new system be flexible enough to enable the supply of the relevant service to be lodged at the appropriate level, whether local, regional or national? The recent welcome improvement of stroke care in London is a case in point. Will the reform encourage greater collaboration and, where appropriate, integration?

My best understanding of the reforms before us today is that they form a continuum, building on the modernisation process begun under John Major, and—with stutters and starts—continued under Tony Blair. Here I declare an interest as I was the Prime Minister’s strategy adviser at the time. Taken together, these reforms are comprehensive and coherent and should address the challenges I have just outlined. They simplify the architecture of the whole health system and lodge accountability for who is responsible for what at every level. In particular, I welcome that they define the role of the Secretary of State not as Minister for the “Today” programme, but as holding ultimate responsibility for the strategic direction and overall effectiveness of the whole system.

These reforms create an arm’s-length commissioning board with the responsibility and the powers to ensure that commissioning is effective. They maintain a system of advice and supervision to promulgate best practice and to safeguard the quality of health service providers. They bring greater openness and transparency, and they allow greater scrutiny of both the system’s marching orders—the three-year mandate—and of the performance of the system overall. They set up, in Monitor, a regulator which can set tariffs to promote best practice and guard against anti-competitive behaviour of any kind. They introduce a failure regime which will maintain essential services for patients while enabling an orderly transition to a more effective alternative. Most welcome of all, they lodge the prime spending responsibility at the front line with GPs and other clinicians, who are far better placed than bureaucrats to make the very difficult trade-offs, and to optimise patient welfare.

These reforms will not be the last word. The NHS will—must—continue to adapt and to change. No doubt the Bill can be further strengthened in its passage through this House. In the round, these measures seem to be another welcome step on the way to the ever more effective NHS that all here desire and want to see.