Health and Social Care

Lord Kakkar Excerpts

Wednesday 5th June 2013 Lords Chamber

[Earl Howe]

I can indeed, and I can do so with confidence because the three chief inspectors that we propose to create—one of whom, the Chief Inspector of Hospitals, has already been appointed—will be working as part of the Care Quality Commission. They will be senior employees of the CQC and their job will certainly be to align the methodology that they use to assess good and poor care.

[Lord Kakkar]

My Lords, I declare my interest as professor of surgery and consultant surgery at University College London Hospital. During the passage of the Health and Social Care Act 2012, there was a discussion about the need to ensure that there was an ongoing focus on integrated care between community hospitals and tertiary services. This needed to be attended by a focus on the development of metrics that would describe whole pathways of care outcomes for patients. What progress has been made with regard to the development of those whole pathway metrics?

[Earl Howe]

The noble Lord hits upon a point of central importance. The outcomes framework clearly sets out where the different parts of the health and care system share responsibility for outcomes and support joint working in the way that I have described. However, we are committed to developing a measure of people’s experience of integrated care for use in the outcomes frameworks. That is a work in progress. Meanwhile, a place holder was included within both the NHS and adult social care outcomes frameworks when they were refreshed in November last year. We have highlighted the development of this measure in the public health outcomes framework, so I hope to give the noble Lord further news in a few months’ time.

NHS: Mid Staffordshire NHS Foundation Trust

Lord Kakkar Excerpts

Monday 11th March 2013 Lords Chamber

[Lord Kakkar]

My Lords, I join other noble Lords in thanking my noble friend Lord Patel for having secured this important debate. I declare my own interest as professor of surgery at University College, consultant surgeon at University College Hospital, and a member of the General Medical Council. There can only be one north star guiding the way we operate in the National Health Service and the way we deliver care, and that must be our patients. In his report, Sir Robert Francis refers to a deterioration in cultures and values. We must find ways to ensure that the cultures and the values that must attend the delivery of healthcare are rapidly restored in our healthcare system.

One way that this may be achieved is by revisiting the question of professionalism. All of us in the health service today work in multidisciplinary teams and, quite rightly, those teams are comprised of clinicians, nurses, other therapists, healthcare assistants and indeed managers who help us to utilise effectively the resources available for healthcare. Those teams can work only if there is mutual respect, but there must also be professionalism.

With regard to clinicians—and I talk here particularly about consultants in hospitals—we need to move to a position where once again consultants are accountable for the management of, and delivery of care for, the patients for whom they have responsibility. They must have the authority to deliver that responsibility for care, and with that responsibility and authority they must be held accountable for the outcomes of their patients. That is very clear. Ultimately, it is vital that patients and the public generally recognise, and are able to have confidence in, the fact that when they are admitted into hospital they will be managed and be under the care of a named healthcare professional—a consultant—who will take that responsibility, have that authority and be held accountable.

In terms of the management of the ward environment, it seems sensible to return to the ward being under the leadership of a named senior nurse—a sister or a charge nurse. Their name might appear at the entrance to the ward, and the name of the consultant responsible for the individual patient’s care might appear under the name of that patient at the head of the bed, so that there is no doubt about who has responsibility for both the ward setting and the individual care of the patient.

In the Francis report, we also see reference to broader questions of culture and values. Part of restoring professionalism will be revisiting once again the contract of employment for healthcare professionals—both consultants in hospitals and general practitioners in primary care. We need to move away from the consultant contract being principally one of contractual obligation and take it back to a place where it is one of vocational commitment, where patients can be absolutely certain that there will be continuity of care and that those with named responsibility for their care will be available to ensure that that is discharged.

The other important area for restoring the culture and values in our healthcare system is leadership. In this regard, in his report Sir Robert Francis has paid attention to the possibility of the staff college model. At University College London Partners, where I have an involvement, I am patron of the UCLP staff college. There, we have taken a model built on the Army staff college at Shrivenham, and we have a faculty from that institution attending our staff college to help to develop the leaders in our healthcare system. The model is simple. It focuses, first, on the self-reflection of those offering themselves for leadership positions so that they might question whether they have the ability to do that, and it then develops a leadership culture that puts at its head responsibility for those whom one is leading to ensure that they are developed to deliver the necessary care for the patients.

The development of leadership, culture and values must also attend the entire period of postgraduate training for all healthcare professionals. In this regard, I should like to ask the Minister what role the local education training boards will play in particular, in conjunction with the medical royal colleges and the General Medical Council, in ensuring that the curriculum for postgraduate training includes appropriate emphasis on culture, values and the development of leadership.

Health: Medical Innovation

Lord Kakkar Excerpts

Wednesday 16th January 2013 Lords Chamber

[Lord Kakkar]

My Lords, I, too, thank the noble Lord, Lord Saatchi, for having introduced this important debate with so much courage and with such intellectual power. In doing so, I declare my interests as Professor of Surgery at University College London, as Chair for Clinical Quality in our academic health sciences centre, UCL Partners, and as an active clinical researcher.

Innovation is absolutely at the heart of improving clinical practice and outcomes for our patients. It is only right that patients, their relatives and the public expect the profession and government to do all they can to ensure, first, that the research necessary to develop innovative treatments and diagnostic strategies is promoted at national and local levels, and that, once we become aware of innovation—be it through research in our own country or anywhere else in the world—it is quickly identified, adopted and placed in clinical practice. Her Majesty’s Government have placed a particular emphasis on this. Driving a research commitment in the Health and Social Care Bill for the first time, ensuring an obligation on the Secretary of State for Health to promote research and development in the NHS, was an important statutory development. We have the commitment of funding through the National Institute for Health Research, the biomedical research centres and their associated units, and the academic health science centres, which all promote early-phase, experimental and clinical research in our healthcare system.

However, Her Majesty’s Government have also recognised the problem of adopting the findings of that innovation and diffusing it more broadly across the healthcare system and across larger proportions and populations of patients. The recent report, Innovation, Health and Wealth, has identified the need for the development of academic health science networks with a clear obligation to ensure that high-impact innovation is quickly adopted and diffused across populations and healthcare systems, and that the recognised therapies that have been shown to have important clinical benefit and are approved by NICE through its guidance mechanisms are applied more broadly across populations for which we are responsible.

We have also heard in this debate that there are important hurdles to innovation in our healthcare system. These hurdles are regulatory, they are potentially legal and they are cultural in terms of the way that clinical practitioners and others work in the National Health Service and healthcare systems more broadly.

With regard to regulation, I should like to ask the Minister about one particular problem that we have heard about today—the European clinical trials directive. I know that Her Majesty’s Government are involved in negotiations at the European level to overcome some of the problems associated with this directive, which has been damaging to clinical research in our country. Is the noble Earl able to give an update on the progress that has been made there and on what changes might be made to this regulation in the future?

With regard to the legal problem, the noble Lord, Lord Saatchi, identified case law which suggests that there may be anxiety in clinicians’ minds about innovating when it comes to the individual patient in front of them. This may indeed be a very important problem and something that needs to be addressed. As we have heard in this debate, it needs to be addressed in a sensitive and careful way to ensure appropriate innovation and to ensure that clinicians who are in a position to innovate do so effectively but that any deleterious effect is not allowed to take place.

Then there is the question of culture. This is particularly important because much of the debate today has focused on what the views of clinicians and researchers, the healthcare system and indeed the Government may be on innovation. However, we must also look at innovation from the patients’ point of view, as well as that of their relatives. They are right to expect that when they need it most, innovation, wherever it is, is responsibly applied to the management of their case. In all the important work to drive innovation, and the research and development of biomedicine that has been achieved in our country so far, we must be sensitive to the fact that we may not be meeting the expectations of patients—our fellow human beings—when they are at their most vulnerable, and therefore more may need to be done to drive an improved culture for the adoption of innovation and the improvement of practice in our country.

Health: Cancer

Lord Kakkar Excerpts

Monday 14th January 2013 Lords Chamber

[Earl Howe]

My noble friend is absolutely right to raise the point. To support the NHS in tackling regional variations in cancer survival rates, we are providing data to providers and commissioners that allow them to benchmark their services and outcomes against one another and to identify where improvements need to be made. Surgical resection is currently the best curative intervention for pancreatic cancer, and through the National Cancer Intelligence Network we have already made available data collections on the survival rates and surgical resection rates across a range of cancers, including pancreatic cancer.

[Lord Kakkar]

My Lords, what proportion of patients diagnosed with pancreatic cancer is managed in specialist centres by a specialist, multidisciplinary team? What proportion of patients in those centres is entered into clinical trials? We all recognise that participation in clinical research improves clinical outcomes in these centres.

[Earl Howe]

My Lords, the UK now has the highest national per capita rate of cancer trial participation in the world, which is something that not everybody realises. We have improved the amount of information available to patients, clinicians and the public about clinical trials by establishing the UK Clinical Trials Gateway. I will write to the noble Lord with information about specialist centres, but he will know that surgery for pancreatic cancer is a complex business and needs to be undertaken by those who are very well versed in that particular line of clinical activity. I am sure that a high proportion will be treated in those centres but I will find out more if I can.

NHS: Clinical Networks

Lord Kakkar Excerpts

Wednesday 12th December 2012 Lords Chamber

[Earl Howe]

My Lords, I am grateful to my noble friend. As regards cancer, it is important to look at what the Government are doing across the piece. As the noble Lord may recall, the cancer strategy that we published a while ago is backed by more than £450 million of investment. This is specifically to target earlier diagnosis of cancer; to give GPs increased access to diagnostic tests; to allow for the increased testing and treatment costs in secondary care; to support campaigns; and so on. That is a large sum of money and it is committed.

[Lord Kakkar]

Does the Minister envisage a role for the to-be-designated academic health science networks in delivering clinical networks in the future? I declare my interest as chair for quality, University College London Partners academic health science partnership.

[Earl Howe]

My Lords, yes. National guidance is being produced by the NHS Commissioning Board, setting out the different areas of focus for academic health science networks, health and well-being boards, local education and training bodies and clinical senates. The defined geographies of the 12 network support teams have been developed precisely to gain close alignment and therefore promote close relationships and co-operation with the other structures in the new system—including academic health science networks.

Nursing Quality and Compassion: The Future of Nursing Education

Lord Kakkar Excerpts

Tuesday 11th December 2012 Grand Committee

[Lord Kakkar]

My Lords, I join in thanking the noble Baroness, Lady Emerton, for securing this important debate and in congratulating the noble Lord, Lord Willis of Knaresborough, on his excellent report. I declare my own interests as professor of surgery at University College, a practising surgeon at University College London Hospitals NHS Foundation Trust and a member-elect of the General Medical Council.

The report that we are considering today is both reassuring and worrying. It is reassuring because it speaks with great optimism about the talented, dedicated and committed people who are still attracted to the vitally important profession of nursing. However, it is worrying because in describing the background that resulted in the necessity for this report, it highlights a worrying deterioration of organisational culture and values that have allowed patients to be characterised as statistics and consumers rather than as vulnerable and anxious human beings coming into our healthcare system and look at healthcare in terms of episodes of delivery of care rather than the delivery of healthcare in terms of compassion and dignity.

This report, rightly, identifies that providing an undergraduate basis for initial training in nursing is not attended by any inability either to develop the clinical skills and standards necessary for this important profession or to ensure that nurses qualify with the appropriate level of commitment and compassion that is vital to delivery of this important profession. The evidence available in the published literature from the United States and Canada shows that for every 10% increase in the number of nurses on the workforce who have reached a bachelor’s degree standard there is a 5% reduction in overall institutional patient mortality. If you look, for instance, at outcomes in surgical practice, the larger the proportion of highly educated nurses, the lower the perioperative mortality. In Canada, there is evidence looking not at surgical patients but acutely ill medical patients: those with heart attacks, strokes and acute respiratory problems. A similar pattern is demonstrated—the greater the level of nurse education, the greater the overall improvement in outcomes, with lower mortality. If one looks specifically, again in Canada, at discharges from acute medical wards, one sees that for every 10% increase in the number of nurses on staff having achieved a baccalaureate or higher level of education, so there is an improvement in survival, with nine fewer deaths per 1,000 patients discharged.

There are four issues in this important report on which I would like to seek further guidance from the Minister. First, preceptorships are very much like the original one year of house jobs prior to full registration with the General Medical Council for doctors, now reflected in the foundation year 1. It has been suggested that these preceptorships should potentially be extended from the original recommendation of four months. However, as is the case with newly qualified doctors, should it be necessary for the dean of the nursing school to have to sign off the graduated candidate at the end of this period of preceptorship before they can achieve full registration with the Nursing and Midwifery Council? This would ensure that those being delivered from the undergraduate programme could demonstrate that they have all the skills necessary to continue to full registration, having had to perform in a potentially stressful clinical environment for a period of time after immediate qualification.

The second area is one of graduate training to ensure that the most able and talented leaders in nursing can rapidly move through their period of post-qualification training and development to take up leadership roles such as those at ward sister level, while still being in a position to deliver front-line clinical care throughout that process.

At University College London Partners, where I chair the quality outputs, we have developed a programme called Excel which does exactly that. It takes the most talented nurses across the organisations within the partnership through a programme of development that will shorten the time from an average of seven years to just four years, in which they can take on senior nursing positions within our organisations, while continuing to maintain a strong clinical focus. Will Her Majesty’s Government support similar programmes across other academic health science networks when they are established, to ensure that we fast-track nurse leaders, helping them to continue their professional development, while maintaining a focus on the compassion and kindness which is ultimately the fundamental basis for all healthcare delivery?

In this debate we have already considered mandatory registration for healthcare support workers. This is a vitally important requirement. As we start to look at teams delivering care, with teams of different skill mixes, it is vital that all members of that team have to perform to a similar level and are able to command the same confidence from members of the public coming into hospital. It does not seem right that only some members of the team are subjected to statutory registration and not others. Have Her Majesty’s Government changed their mind on this? Are they now in a better position to recommend and provide a statutory basis for such registration?

Finally, on revalidation for nurses, as we move to a graduated profession it will be vitally important that, as we see with revalidation for doctors, nurses are also subjected to revalidation to ensure that the skills that they have developed early in their career are maintained throughout it. At the moment, registration requirements are reflected in 450 hours of practice in a specialist area over three years, and 35 hours of continuing professional development on an annual basis. But revalidation means much more than this. Will Her Majesty’s Government provide a statutory underpinning for revalidation of the nursing profession?

NHS: Diabetic Services

Lord Kakkar Excerpts

Thursday 29th November 2012 Lords Chamber

[Lord Kakkar]

My Lords, I join others in congratulating the noble Lord, Lord Harrison, on having secured this important debate and declare my own interest as professor of surgery and consultant surgeon at University College London Hospitals NHS Foundation Trust. We have heard during this debate about the profound burden of diabetes in our country. Some 24,000 excess deaths are reported in those with diabetes annually, some 13,000 strokes, 11,000 heart attacks and more than 4,000 minor and major amputations, in addition to the complications seen in the eye, the kidney and the nervous system. All have a profound impact on the individuals who suffer from this potentially devastating disease. As a result, and quite rightly, diabetes has received an awful lot of attention, not only in clinical practice and research but in government during the past 10 to 12 years, with the growing recognition that the burden of this chronic disease on society and the National Health Service will be profound.

The recent inquiry by the Public Accounts Committee in the other place failed to reach a consensus position with Her Majesty’s Government on the cost to the National Health Service of diabetes, but the figures range between some £4.6 billion and £10 billion, looking at the broad impact of the disease on NHS services. This is quite striking at a time when the service needs to spend its resources more efficiently and effectively. Among the issues raised in that report are: how diabetic services should be commissioned, why commissioning to date through primary care trusts appears to have failed patients and how looking at the new arrangements for the delivery and commissioning of NHS services as a result of the Health and Social Care Act 2012 might be used to improve outcomes for diabetic patients.

What we know in terms of reports and strategies such as the national service framework in 2001 and the production of NICE clinical standards in 2011 is that simple interventions provided annually for patients with diabetes can have a profound impact on improving their clinical outcomes. These include, for instance, annual examination of the eyes to determine whether patients are developing retinopathy; annual, or more frequent if necessary, examination of the feet to guard against diabetic foot complications; regular measurement of the blood sugar, particularly glycosylated haemoglobin, to determine whether the longer-term management of sugar is appropriate; the evaluation of blood lipids and blood pressure, because cardiovascular complications in diabetics can be more devastating and occur with greater frequency; and, of course, testing the urine for protein and testing the blood for creatinine to determine whether the kidney is being affected by diabetes and whether more careful clinical attention needs to be paid to protecting that important organ. In addition, it is well recognised that education of diabetics is vital. Of course, the preparation of women with diabetes for pregnancy is vital, too, to ensure that we do not see the devastating potential complications of diabetes during pregnancy.

These complications and the measures are well understood. What is often forgotten is the fact that diabetics entering hospital for management of other conditions will often have complications at a much higher rate and frequency as a result of having diabetes. One of the most important is, of course, the development of infection in hospital, which is seen more frequently in patients in whom diabetes is not appropriately controlled. It is quite right to say that multidisciplinary care is vital.

To return to the NICE care standards and processes described—simple, authoritative measures—if we ask how frequently and successfully those are being applied to patients with diabetes in communities around the country, the data are quite startling. For interventions that could prevent a heart attack, stroke, amputation or early death, we find that only 50% of diabetics have all nine simple care measures applied on an annual basis. In two PCTs, less than 10% of patients have those nine standards assessed on an annual basis, and in the best PCT only 69% have those measures conducted on a regular basis. The reality of the situation is that the Department of Health, giving evidence to the Public Accounts Committee in the other place, stated that 100% achievement of these nine care processes was unrealistic and a more realistic target was only 75%. That seems rather disappointing, bearing in mind the burden not only for the individual patient but for society more generally and the NHS in terms of its resources attending complications of diabetes.

It is clear that the current arrangements for holding commissioners to account have failed. Of course, we will see the disappearance of those arrangements—and of primary care trusts—on 31 March next year. The provision of these appropriate care measures to much larger numbers of diabetic patients would be a first, early and important test of the new commissioning arrangements through the NHS Commissioning Board and the clinical commissioning groups.

With that in mind, is the Minister able to say what progress has been made with regard to putting at the centre of diabetic care the provision of integrated care pathways? It is quite right for a chronic condition that the majority of care should be provided in the community setting but it is also very clear for diabetics that provision of or access to ancillary services is vital. We have heard about feet and eye services, but there is also access to specialists in hospital because diabetes is much more than a disease of blood sugar. It is a complex metabolic condition with profound cardiovascular, neurological and peripheral vascular implications. It is very important that any commissioning arrangements incentivise excellent care in the community but also make it mandatory for early referral to more specialist centres for early intervention on developing complications.

In this regard, will the quality outcomes framework in primary care be modified to incentivise integrated care? Will payment by results for secondary and tertiary care providers ensure that integrated care across multiple providers in the community and in hospital becomes the norm rather than the exception for the provision of the management of diabetes? In addition, if more care is to be given at the primary care level, it is vital that general practitioners are properly trained and continue to receive ongoing training and professional development to ensure that appropriate care is given to diabetic patients, and that we have an emphasis on ongoing research in both the primary and secondary environments if more patients are to be managed out of hospital.

Finally, the question of the role of Public Health England has been raised. This is a major societal problem with major public health implications. It is critical that Public Health England takes as one of its early priorities the question of screening for diabetes in high-risk populations—for instance, in certain ethnic minority communities, as we heard about from the noble Lord, Lord Harrison—and sees that every opportunity is used to ensure that patients who develop diabetes can be identified early rather than later and that intervention can be provided to avoid potentially devastating complications.

NHS Commissioning Board: Mandate

Lord Kakkar Excerpts

Tuesday 13th November 2012 Lords Chamber

[Baroness Cumberlege]

My Lords—

[Lord Kakkar]

My Lords—

--- Later in debate ---

[Earl Howe]

My noble friend makes a series of extremely important points and I agree with everything she said about maternity services. Emergency services will be commissioned at a local level by clinical commissioning groups but that cannot be the end of the story. She rightly implied that paramedics and trauma care doctors require skills in sometimes very sophisticated techniques of maintaining life at the scene of an accident, for example, and hospital procedures. These skills must be maintained and improved. The short answer to her question is quite consciously missing from this mandate. This is the need for Health Education England to work very closely with the board because the Centre for Workforce Intelligence and Health Education England will have to ensure that we have not only the right numbers in the NHS workforce but those with the right skills and the right level of skills. As she rightly said, we also need to educate the public that the health service does not consist of a series of buildings; it consists of a network of services. We will have advanced considerably if the public can understand rather better than they generally do that the continuation and improvement of services matter, rather than bricks and mortar.

[Lord Kakkar]

My Lords, I declare my interest as Professor of Surgery at University College London Hospitals NHS Foundation Trust. I very much welcome the noble Earl’s indication that the five objectives of the mandate are now clearly linked to the five parts of the outcomes framework. However, successful and meaningful commissioning decisions will critically place intense focus on the development of metrics in the outcomes framework. Local commissioning will be completely meaningless without objective metrics set as part of the commissioning process at a local level and without the ability to measure those outcomes. With specific emphasis on chronic conditions, what progress has been made on integrated care pathway metrics for integrated care both in the community and in the hospital? If there is little progress, when will we ensure that we have integrated care pathway metrics available to ensure that we drive forward meaningful local commissioning decisions?

[Earl Howe]

The noble Lord has alighted on an extremely important area. We have been very careful in constructing the outcomes framework to make sure that we define deliverable outcome indicators. The NHS Commissioning Board is satisfied that the indicators are realistic but I have to be candid with him. This represents work in progress as the precise way in which the board will demonstrate that it has made progress against each of the indicators has not been defined in every case. I can assure him that it will be. It will be up to the board, however, to construct a system of local accountability to ensure that the clinical commissioning groups are held to account against realistic demonstrable indicators which match those of the NHS outcomes framework, not least in the area of chronic conditions. The patient pathway is work in progress, too, but much of its quality can be measured by reference to the patient experience. That is one of the central domains of the outcomes framework, on which a lot of work has been done. I would be happy to write to him on that.

NHS: Professional Qualifications Directive

Lord Kakkar Excerpts

Monday 15th October 2012 Lords Chamber

Asked by

[Lord Kakkar]

To ask Her Majesty’s Government what progress they have made in negotiations at European level on the working time and recognition of professional qualifications directives in the light of their impact on the delivery of care in the NHS.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, negotiations on both directives are ongoing. The Government remain of the view that both measures should support labour-market flexibility without imposing significant extra costs on member states to ensure that any negative impacts that we have seen are ameliorated and, most importantly, to ensure that patient safety is maintained.

--- Later in debate ---

[Lord Kakkar]

My Lords, I declare an interest as professor of surgery and consultant surgeon at University College London Hospitals. In today’s Daily Telegraph the presidents of the Royal College of Surgeons and the Royal College of Physicians make an urgent plea for action on these two elements of legislation to halt a devastating deterioration in clinical training and patient safety. Do Her Majesty’s Government collect data on the number of patients harmed as a result of the implementation of these two directives, for instance from coroners’ inquests where they have been implicated in patient deaths, and on the financial consequences in terms of the employment of locum doctors in the NHS to ensure that hospitals are 48-hour-week compliant? If these data are not collected will the Minister commit to organising for their collection in the future to better inform this Parliament and to add impetus to the Government’s negotiations with their European partners?

[Earl Howe]

My Lords, it is the responsibility of individual NHS trusts to ensure that service rotas are compliant with the working time directive. In line with the Government’s coalition agreement to reduce duplication and resources spent on administration, the department reduced bureaucracy for the service by removing the burden of central monitoring of compliance and we are leaving this role to organisations at local level. The last assessment of the working time directive was undertaken in January 2010 and reported that nearly 99% of doctors’ rotas were compliant with the directive but we are in no doubt about the concerns that exist within the medical professions about the inflexibilities within the rules of the directive. As regards the mutual recognition directive, the department does not plan to collect directly any data relating to it. The professional regulators. who are the competent authorities, collect data in respect of the number of people applying for recognition under the directive.

NHS: Health Workers

Lord Kakkar Excerpts

Thursday 19th July 2012 Lords Chamber

[Lord Kakkar]

My Lords, how will clinical leadership be developed to secure the appropriate culture and values essential for delivery of safe, effective and dignified care for all NHS patients?

[Earl Howe]

There is a clear role here for the professional bodies. Training should be done in the right disciplines and numbers and in the right way. I am sure I do not need to tell the noble Lord that in virtually all the medical royal colleges and through the Royal College of Nursing, there is an increasing emphasis on leadership backed by resources from the Department of Health. We are seeing a drive forward for innovation and the breaking down of professional barriers, which is another aspect of this issue.