NHS: Global Health

Lord Crisp Excerpts

Monday 20th December 2010 Lords Chamber

Tabled by

[Lord Crisp]

To ask Her Majesty’s Government how they will ensure that the subject of global health is included in the education of all health professionals.

[Lord Crisp]

My Lords, it is a great pleasure to be able to open this debate. I am delighted to see how many noble Lords have decided to take part in it, and I know that a number of others, for reasons of snow and the fact that we already had a large list, have decided not to take part. There is a lot of interest in this subject, and it is something on which there is a great deal of agreement both in your Lordships' House and outside. That agreement is partly the point of the debate, because what we need now is some action.

Professional education in the 20th century has done a wonderful job, not least in the United Kingdom. Life expectancy in the world as a whole has doubled in the century, but the outside world has changed, which means that there is a need for a change in education. There is a broad consensus on what needs to happen, and we can see it happening in many of our leading schools already. As Richard Horton, the editor of the Lancet, has put it:

“health professionals today are not adequately prepared to address the present and coming health challenges—aging populations, chronic diseases, cultural diversity and higher public expectations”.

It is, if you like, the necessary move from a purely doctor and hospital-based model to something much more diverse and local, more community and more person-based. That was a goal of the last Government and I know that it is a goal of this Government. The difficulty as always is to make it happen.

This Question is about global health and the emerging new discipline of global health. Let me explain why I think it is relevant here. I am talking about global health, not international health, which is what we talked about in the last century when we talked about the health of other people. Global health is about the health of all of us—all the issues that affect us all, wherever we are in the world. It is about our interdependence in terms of disease and how it can fly around the world very quickly; in the 14th century, it took three winters for the Black Death to get across Europe, whereas it took three days for SARS to get around the world earlier this century. We are also interdependent in our use of the same staffing and resources and interdependent in terms of the environment and climate change. All kinds of issues affect our health and we began to understand them much better in this past decade than we ever did before.

The second reason is that the diseases from which we suffer have been changing. There are many more non-communicable diseases, and in that context context itself is vital. We are beginning to understand better the social, behavioural, cultural and economic aspects of global health, and the emerging discipline is about taking on these issues and about understanding and acting on the wider determinants of health. Education needs to do this as well.

Thirdly, global health is about recognising that health is about health systems and how healthcare is delivered to individuals and populations. It is not just the theory of the laboratory and lecture room but the reality of the clinic and the community.

The fourth point that drives very many people is that experience in other countries is extremely valuable to us in the UK. Many who are involved in global health are driven by a passion to do something in poorer countries, but it is good for the UK as well. It develops people personally and they can learn from new examples and new experiences, and of course learn about some of the people living in their own country whose origins may have been far away.

Let me refer to the recent Lancet commission report that was published at the end of November, called Health Professionals for a New Century: Transforming Education to Strengthen Health Systems in an Interdependent World. The commission was chaired by Julio Frenk of the Harvard School of Public Health, and by Lincoln Chen of the China Medical Board, of which I was privileged to be a member. This was the first such attempt to look globally, with a global set of commissioners, and to learn from innovation everywhere in the world—not just Europe and America—and to do so across all professions on which we could collect data. It draws out some key lessons about how education needs to happen in the future: about how it needs to be interprofessional and transprofessional, going across disciplines and outside them to involve the public. Education needs to be competence-based, systems-based and IT-enabled.

The report also shows how our institutions need to change, breaking down barriers and connecting not just across disciplines but going outside health across locations and countries. Let me mention just one example that brings it alive: the IHI Open School. There are now 80 chapters in universities across world in 28 countries. This is a coming together of medical students to learn via the internet about subjects that are not covered in traditional courses: quality improvement, systems thinking and such like. They are studying in one school, maybe in the UK, but adding to it from elsewhere. This is the sort of model that I think we will continue to see.

The final point about the report is that it talks about transformational education: the effort to create professionals who are able to lead and make change in today's changed world. A brief illustration of the wide-ranging thinking on this in this country can be seen from the activities of two groups: Alma Mata and Medsin. Alma Mata is a 1,000-strong group of junior doctors and young health professionals from other disciplines. Medsin is also about 1,000-strong and made up of medical students. They advocate precisely that global health should be included in the syllabus and set out their vision for the doctor of the future, which is very important as they are the doctors of the future.

It is encouraging to see that the establishment is responding, including the Royal Colleges—and we have two former presidents of Royal Colleges speaking in this debate. To take one example, the Royal College of Obstetricians and Gynaecologists is very concerned about the lack of support for junior doctors who want to work overseas and who want to include that in their training and not be disadvantaged in their careers by doing so. There are also organisations such as the London International Development Centre, which works with six London institutions and runs, among other things, courses of students as global citizens. There is a very much wider view here about what needs to change. Indeed, developments in partnerships between institutions are very ably supported by THET, and I am delighted to know that Her Majesty’s Government through DfID have launched an even more substantial scheme to promote these partnerships.

There is a lot happening in the UK, but this is a worldwide phenomenon and things are moving faster in the US and Scandinavia than here. I can imagine the Minister saying, “Very good, we’re happy to encourage this, but what has this got to do with Government and the Department of Health?”. My answer is that it really does have an impact on us. I stress that this sort of activity is not just for the benefit of foreigners; it is about creating better health professionals who are better able to care for people of this country with our 21st-century diseases and lifestyles.

I suggest three actions. The first is extremely practical. I ask officials in the noble Earl’s department to report to him on what more can be done to help trainee doctors to spend some time abroad as part of their training and to do so in some numbers, not with the odd one or two who take a risk with their careers. That would make this much more mainstream and much more positive.

Secondly, the Minister’s department should meet the universities and the professional education schools of medicine and nursing and the wider health schools to consider the findings of the Lancet commission and decide what action might jointly be taken to develop the education of health professionals and to get some impetus and coordination behind the moves that are happening all over this country.

My third request is that the Minister’s department provides active support for the involvement of NHS people and organisations in the DfID programme of partnership, recognising that this is a difficult time for the NHS but making it clear from the top that this is good thing for people to be engaged in. It is about the future, and there may even be ways of looking at things like the newly announced early retirement scheme, which might actually help in developing these sorts of programmes.

Health: NICE

Lord Crisp Excerpts

Wednesday 3rd November 2010 Lords Chamber

[Earl Howe]

My noble friend, with her experience, is of course quite right. I am told that it costs upwards of $1 billion to develop a new molecule and bring it to the market. It is a very expensive process. That is recognised in the freedom of pricing that currently exists for drug companies at launch and in the patents that they are able to enjoy in subsequent years.

[Lord Crisp]

My Lords, I declare an interest as I was in the Department of Health at the time that NICE was created. If the Minister accepts that the NHS, which spends upwards of £11 billion a year on drugs, is right to have a clinically-led method of assessing whether they work satisfactorily, will he confirm—there seems to be some confusion—that that will not be replaced by some hundreds of separate ways of doing the same thing? Will he also confirm that, whatever new arrangements he has in mind, the Government will speed up the process? There is sometimes that complaint about the NICE process at the moment.

[Earl Howe]

My Lords, we have been very clear that NICE, which enjoys international pre-eminence in the evaluation of drugs and health technologies, will continue to have an important expert advisory role, including the assessment of clinical benefits for new medicines. The noble Lord will know, I am sure, that in recent years NICE has done a lot to speed up its evaluations of new medicines and has introduced end-of-life flexibilities, for example, which have meant that patients have had increased and improved access to those new medicines.

Health: Primary and Community Care

Lord Crisp Excerpts

Thursday 24th June 2010 Lords Chamber

[Lord Crisp]

My Lords, I, too, congratulate my noble friend Lord Mawson on inviting us to reflect on primary care over the past 10 years and more. I know he is hopeful that his timing is such that the Government’s policy is not yet so rigid that they cannot listen to new ideas and the practical lessons that he and others want to mention. I have to declare an interest. Most people know that I was chief executive of the NHS in England for six years. There is a lot that I could say, but I will concentrate on the same areas as my noble friend; namely, the integration of care, particularly thinking about social care, education and other boundaries around the whole person.

The other day, an American friend said to me, “We love you in England because you keep changing the way you develop primary care. You are a wonderful laboratory. You have tried out lots of different ways of doing it”. I guess that that is true. But I guess that there is a reason for that, which is not just a wish to meddle. It is that, as other noble Lords have mentioned, a lot has changed in the 70 years since the 1940s, when we set up the primary care system we have now. The three big changes have been referred to by others. The diseases are different. Seeing patients is much more about dealing with non-communicable diseases. They are about elderly people with complex or multiple problems. The patients have changed. They are much more demanding, but their behaviour is much more important in so many ways in terms of the management of care for diabetes or whatever. In addition, technology has changed. All those changes mean that our old model has led to shift. As we have noted, there have been many ways in which people have tried to make that shift. It is really important that we learn the lessons from those attempts to change and to make improvements.

Before this debate, the Royal College of Physicians wrote to me and, I suspect, to others saying that it was really important that we did not lose sight of the fact that primary care, secondary care and tertiary care need to join up. We need to have that all within the frame. It is interesting to reflect that the separation between primary care and secondary care is largely in legislation that is about 70 years old. It is not writ that a GP shall be this and a consultant shall be that. It was an organisational change. The way in which parts of the medical profession relate can change and some organisations, as I think that the noble Lord, Lord Alderdice, mentioned, employ or involve both. There is nothing rigid about this.

However, I want to talk about integration around the patient. Let me go back to the simple point that most patients today in richer countries are people whose needs often may be clinical, but alongside that there is a need for independence. I think that I have mentioned in this House before that my elderly father fell and broke an arm. Clinically, it was very easy to deal with, but the real issue was whether he could remain independent and live at home by himself. That is the sort of situation we are talking about in terms of many of the patients that the NHS deals with. Indeed, many patients with the highest expenditure in the NHS are those with complex problems that span clinical, social and other needs. So it is welcome to see primary care playing a major role in prevention and in helping patients find their way around the system.

Primary care is not just about GPs, and it is important to keep the two separate. There are different roles for many different people. One of the saddest pieces of research I have seen was published some years ago. It concerned young people suffering from depression and how they were treated in primary care and whether they were able to be taken seriously. There were too many accounts of people going to GP surgeries and being told to come back in three months if it was getting worse. In effect, they were being turned away. We need different routes in primary care for those who sometimes find it difficult to express their needs.

That takes me on to the issues raised by the noble Lord, Lord Mawson, about health and social care, and other areas such as health in education. He asked how far we should go to ensure that we have health provision in schools, whether in the form of health services or whether they are designed into the architecture of schools. He also asked if we should have local partnerships that are able to focus on what is needed. The noble Lord concentrated on social entrepreneurs, but I know that he, like me, is interested in how local partnerships made up of the right groups of people can have an enormous impact on a local environment in terms of health benefits and the related issues that go alongside them. By local partnerships, I am not just talking about individual organisations that bring health and social care together, but about partnerships that bring together everyone who has something to offer in this area. These can be quite difficult to conceptualise and describe in order to determine the policy that will promote them, so I would encourage the Government to look at some of the ones that work.

As I said, the noble Lord, Lord Mawson, referred to a number of social entrepreneurs and one or two exceptional GPs who have set up extraordinary practices that go way beyond what we would traditionally think of as healthcare. But I think that some of our PCTs have done exceptional things in trying to address inequalities, particularly in areas like mental health where we know that among the best things you can do for patients is help them to get jobs and housing. Among the range of entrepreneurial PCTs let me mention one particular group I know of and declare an interest in. Something like 20 UK PCTs are part of a group called Triple Aim. They are working alongside similar organisations in Scandinavia and the US, facilitated by an American organisation called the Institute for Healthcare Improvement. Here I declare my interest because I am working with the organisation in Africa rather than in this country. It would be interesting for the Minister and the Department of Health to look at what these PCTs are trying to do by taking on a triple aim—to improve the health of the population, improve the care given to individuals, and reduce costs. They are doing so by trying to integrate with local partners. There are some good examples that we can build on and, taking a completely different example, a number of schools in this country have health facilities within them. So I urge the Government to look not just at the social entrepreneurs referred to by the noble Lord, Lord Mawson, but at the organisational people working within the system who are trying to make these things work; they go very much together.

Finally, I come back to the issue of primary care trusts and GPs. I have seen some statements from the Government about giving GPs and doctors more control. I understand and appreciate that. One of the great merits of the NHS that shows up in any comparison with other systems around the world is its primary care. This is one of our great strengths, among others, and we must preserve it. But however wonderful some GPs are, not all of them are. They are not all capable of taking on all the roles that we might think we would like them to. I pay tribute to the last Government because they were concerned about variations in performance between hospitals and did a great deal to bring the performance of the poorest up to the best. Among GPs, not surprisingly because there are so many of them, that range of variation is much wider. Sometimes we talk about GPs as if they are all the same, but to me that feels like something of a mistake.

Another issue in developing policy around GPs in the context of primary care is the potential for conflicts of interest, and again I suspect that the Department of Health has good examples of where, by putting more money into primary care decision-making hands, potentially and only in some areas you end up with conflicts of interest about how the money is spent. But—and it is a very big but—we have also seen great benefits from having primary care and GPs taking a lead. In particular, it is interesting that in a number of practices where the GPs have budgets and have taken a bigger lead around commissioning, they have changed the services they provide and the job roles of people. Increasingly you see people other than individual GPs when you attend a GP practice. That is all for the good, in both quality and cost terms.

I am reminded that 15 years ago we were trying to get more GPs into east London and tried to do so by recruiting salaried GPs—in other words, by moving away from the current model of GPs being self-employed. We were told we could never do that: it was not what GPs were about and it was essential that GPs were independent. I see the noble Lord, Lord Rea, nodding his head. However, we succeeded to some extent in making that happen but now it has all changed. Today, in practices where GPs are responsible for budgets and direct care, there are many salaried GPs and many people doing different kinds of jobs. That would not have been possible had you tried to make those changes from above. Indeed, GPs in London complain that they cannot get jobs as partners any more; there are now salaried jobs but the partnerships are being kept in fewer and fewer hands.

While that may be a downside, the important point is that doctors, as part of the entrepreneurial culture to which the noble Lord, Lord Mawson, referred, have the ability to make changes that mere managers, politicians and others from outside would find it difficult to make. It is important to build on that.

I hope that, like the noble Lord, Lord Mawson, the Government will look back on the years of change and development and learn the practical lessons. I should like to ask two specific questions. Will the Government look at innovative PCTs as well as innovative entrepreneurs, and perhaps consider Triple Aim as an example? How will the Minister clarify the relationship between PCTs and GPs in the future? I suspect this is one of the areas in which there is some confusion in the service at the moment over how primary care will be led, planning will be done and life will move on over the next few years.

NHS: Patient Targets

Lord Crisp Excerpts

Wednesday 23rd June 2010 Lords Chamber

[Earl Howe]

My noble friend is right because, when all is said and done, many of the centrally imposed targets were quite arbitrary. For example, why 18 weeks, not 17 or 19? It is worth saying that the targets that clinicians and managers set themselves are often a great deal more stringent than the ones that politicians are likely to set.

[Lord Crisp]

My Lords, as the chief executive of the NHS in England from 2000 to 2006, I think that I had better declare an interest on this matter. Although what the Government announced recently were some minor and probably quite sensible changes to targets, they also sent a big message. The message is about localness, which is very welcome, but there is also a very risky message, which is that waiting no longer matters. I know that the noble Earl understands very well that the NHS listens to what Ministers say. How will he ensure that people in the NHS understand that waiting is still a very important issue?

[Earl Howe]

My Lords, the noble Lord is absolutely right. I believe that the message that he wants sent has been sent by the NHS chief executive in his letter to NHS bodies. It is certainly a message that the Government want to send. Timeliness is important. A great deal has been achieved. We do not want to squander that, but we think that clinicians should now be given the responsibility to prioritise patients and treatments for themselves, not have central performance management dictated from above.