Health and Social Care Bill

Lord Kakkar Excerpts

Tuesday 25th October 2011 Lords Chamber

[Lord Davies of Stamford]

I certainly agree with the noble Baroness on that. If I have to speculate again, the only hypothesis that I can credibly come up with is that the education and training requirement was not initially in the Bill because the whole thing is a hurried, makeshift, politically driven, ill thought through and frankly almost frivolous exercise—an appalling way to treat a great national institution of which we are all so proud.

I return to the publication of the White Paper in 1944, to which the noble Lord, Lord Walton, referred. He even lobbied the Minister at the time, Mr Willink. It was before I was born and it is wonderful to see the noble Lord in such great form all these years later, defending the NHS. It was an all-party achievement. I am afraid that the Conservative Party in its modern form no longer has the deep commitment to what many of us feel is a matter of national consensus that we hope will continue.

I repeat that this is in no way a personal attack on the Minister: far from it. He did everything that he could to remedy the situation. However, the Government right through the election campaign were against any kind of top-down reorganisation of the health service. They come out with a half-baked Bill, are immediately attacked from many sides and make concessions. People continually run to David Nicholson and say, “You’d better redraft this or that, we haven't thought about this, we have a problem here, what do we do about this?”. David Nicholson dashes off something on a piece of paper and we get another amendment. It is not the way to legislate on any serious matter. It is certainly a lamentable way to legislate on our great National Health Service.

[Lord Kakkar]

My Lords, I strongly support the amendment in the names of the noble Lords, Lord Walton of Detchant and Lord Patel. I remind your Lordships of own interest as professor of surgery at University College, London. I point out that of all the Members of your Lordships' House who have a background in medicine, I completed my training most recently, some 12 years ago, and am acutely sensitive to the fact that training is vital if we are going to deliver high-quality care. I still remember vividly, and benefit from, the instruction that I was given in my training as a general surgeon.

The purpose of the Bill is to ensure that we provide the highest quality healthcare, achieving the very best outcomes and always putting the interests of the patients of our country at the centre of everything that we do. For this purpose, we need to achieve two fundamental objectives. We need high-quality education of undergraduates to prepare them properly for a life in any of the healthcare professions and to inspire them to be excellent doctors and other healthcare professionals. We must also ensure in postgraduate training that we train future doctors and other healthcare professionals to develop the skills that they require to deliver the best for our patients, and the judgment to apply their skills in an appropriate fashion.

Our system of training is so good and respected throughout the world because it is clinically based. Throughout, those who are fortunate enough to be taken on for training in positions in the National Health Service are exposed to, and have the great privilege to be involved in, the care of the patients of our country. However, the delivery of education and training is a hugely complex issue. Not only must we have the matter in the Bill; it must be dealt with in detail. Notwithstanding the fact that Her Majesty's Government propose to introduce a further Bill to deal with education and training in healthcare, which will be hugely welcome, in the intervening period we must recognise that the delivery of healthcare is integral to the delivery of education and training.

I give an example from training in surgery. Consultants who wish to take on training responsibility have to be trained to do so. They must make time available to have the training to become a trainer. They need to organise the delivery of their clinical practice in the care environment in which they work in a thoughtful fashion, to provide training opportunities for their trainees. Frequently that will mean that the utilisation of NHS resources is less efficient than if the facilities and sessions were delivered purely by a consultant. Training takes time; trainees work at a slower rate; they interrupt what they are doing to seek guidance; and they must be provided with the confidence to become good practitioners.

Beyond that, we need to release those working in our healthcare systems to support medical royal colleges and other professional bodies to set and then supervise the standards of training that must be applied across the National Health Service. That takes them away from clinical practice and again makes the utilisation of the resource potentially less efficient. For trainees, we have to provide an environment that supports training. This is complex, because it requires not only release from service commitments—again, this has an impact on resource utilisation in healthcare systems—but time within the delivery of clinical practice to learn to develop judgment in a fashion that is less efficient than it would be if the clinicians had been fully trained as medical or other healthcare practitioners.

For this reason, I strongly support the amendment that education and training must appear in the Bill as a commitment, an obligation on the Secretary of State for Health. We must also spend more time dealing with the issues that might present problems between the enactment of the Bill and the subsequent appearance of a future health Bill that deals specifically with education and training.

[Lord Warner]

My Lords, I support Amendments 2, 6 and 44 in particular in this group. However, I am sympathetic to and support the other amendments. The debate is going downhill. Following the eminent doctors, noble Lords will now get the perspective of a jobbing ex-Minister who was responsible for workforce matters in his time. What is particularly attractive about this set of amendments is not just that they put education and training of staff in the Bill, but that they bring a proper national perspective to this set of issues. I want to talk more about that national perspective because it is often lost sight of as people get very concerned about the responsibilities of employers at the local level. Of course, employers at the local level have a lot of responsibilities. They have the responsibility to ensure that the people they appoint to particular jobs have the skills, expertise and character, and can actually do those jobs. However, the sphere of operation of many of these local trusts, or even GP practices, is quite small geographically and they simply do not have the perspective to do the kind of planning that is required.

My noble friend Lord Davies said that planning is a dirty word. I am a child of the 1960s and was brought up to think that planning was rather a good idea, and I still think it is rather a good idea. Trying to work out what you want to do in the future seems quite a sensible way to run a National Health Service. We need to accept that there is a national role for the Secretary of State and the Department of Health in workforce planning and development. If you do not believe me, it would be worth going back to some of the Health Select Committee reports on this issue under the previous Government, which are very condemnatory of historical approaches by the Department of Health to doing good workforce planning across the NHS.

The issues that arise in this area for a Minister sitting in Richmond House are not ones that you can leave to employers at the local level to deal with. These issues are of long-standing provenance, such as the relationship between doctors from other parts of the world coming to work in the NHS, immigration law and the European working time directive, which has had a massive influence on the way doctors work. We cannot expect local employers to sort these issues out. We also have other big issues to consider; for example, revalidation of health professionals to ensure that they can and do keep up to date.

Another area where the previous Government have a lot to be proud of is the development of a range of sub-medical professionals who could take on jobs to relieve doctors to do more significant work. A good example of this was emergency care practitioners in the ambulance service, where totally new groups of people were brought in, who turned the ambulance service, if I may put it this way, from being just a taxi service to a hospital into a service that had people who could keep patients alive until they got to the hospital. We have a good tradition of developing those areas but in many cases, after a lot of good pilot schemes were introduced by particular local employers, the NHS was reluctant to go to scale. Nurse prescribing is a very good example where we trained lots of nurses but local employers did not always use them to do the job they had been employed for. You need some national perspective to tackle some of these areas.

I now want to say a few words about the much-maligned strategic health authorities. It has become fashionable to say that they were just bureaucratic empires that did not do anything terribly worthwhile. I am still proud that I set up 10 SHAs. They did a good job. The Government will find that they will need an intermediate tier between Richmond House and clinical commissioning groups and local trusts. No one has run the NHS since 1948 without an intermediate tier. The strategic health authorities were the hosts; they worked with the deans and helped to do some of the workforce planning and development in this area. They were the people you could rely on if you needed to ensure that there were enough training places at the local level for the next generation of doctors to secure their specialist training. If you do not have some capacity at that level, you will end up with the really rather difficult problem of how to find the training posts for the next generation of doctors to undertake their specialist training.

Health and Social Care Bill

Lord Kakkar Excerpts

Tuesday 11th October 2011 Lords Chamber

[Lord Kakkar]

My Lords, I thank the Minister for his thoughtful introduction of this Bill and in so doing declare my own interest as professor of surgery at University College London and as consultant surgeon to University College London Hospitals NHS Foundation Trust. It is as a practising surgeon that I recognise the need for Governments to attend to the question of the National Health Service through the introduction of Bills that ensure its long-term sustainability.

I also welcome the personal commitment to the National Health Service of the Prime Minister, the Deputy Prime Minister and the Secretary of State for Health. Those commitments, however, and indeed the introduction of this Bill, are themselves not sufficient: as we have heard from the noble Earl, Lord Howe, any Bill addressing the future of healthcare in our country must address the serious challenges that all healthcare systems around the world face.

These challenges represent the demographic change in society, with an ageing population attended by more chronic disease requiring ever greater intervention; the need to improve clinical outcomes to ensure that our patients receive the best healthcare possible and that this is done with due attention to the introduction of innovation, technology and new methods of treatment to achieve those improved outcomes; and, finally, that the provision of healthcare is delivered in the most cost-effective fashion to ensure that the vital funds available for healthcare are used most appropriately, recognising that the our economy faces a very serious challenge and will do so for many years to come and that the funds available for all public services, including healthcare, will therefore be limited.

How are we to chart these dangerous and difficult waters? I believe that our north star should be the patient and our road map the National Health Service Act 1946. That Act has defined the way that healthcare has been delivered in our country for six decades—and rightly so. But the legacy of Bevan’s settlement has some important problems today with regard to the delivery of healthcare, specifically with regard to a particularly centralised approach to decision-making and the failure to engage at the outset primary care practitioners.

This Bill has the opportunity to deal with those two important issues in such a way that the foundations of the NHS, laid in 1946, can be built upon. If those two issues are addressed successfully, then local talent and innovation, driving the development of new therapies and new ways of delivering care, will help improve clinical outcomes. Full engagement of our colleagues in primary care, in the management of the service and its resources, will better help us connect with patients, the focus of our service.

There remains considerable anxiety about this Bill, not only among healthcare professionals, but among the people of our country more generally. As we have heard, this Bill comes for consideration at a time when our nation faces considerable challenges and difficulties. The national state of mind is one of anxiety, but there is also professional anxiety because of the scope and potential complexity of this Bill, which may be attended by unintended consequences that could disrupt the provision of universal healthcare. The profession is also concerned because previous reorganisations and upheavals, although well meaning, have not always delivered the benefits that were intended, and sometimes have had detrimental consequences.

It is the responsibility of your Lordships’ House to move forward with careful consideration of all matters in this complex Bill to allay those anxieties, having undertaken very effective scrutiny and, where necessary, appropriate amendment of the Bill.

I have a number of specific concerns beyond the accountability of the Secretary of State and how competition on the basis of quality will be promoted. I am concerned about how the new clinical commissioning groups are going to discharge their responsibilities in accordance with the Nolan principles of standards in public life. These are new public bodies and they will potentially be in a conflicted situation in their localities. These standards in public life need to be strongly promoted and maintained.

I am concerned also about how we are going to focus on outcomes in primary care and ensure that the delivery of primary care meets the very highest standards within the structures that are proposed. As a surgical academic, I am concerned about the potential impact on teaching, training and research, although I believe that there are opportunities for the Bill to address those issues and ensure that the vibrant academic basis for medicine in our country is strongly promoted.

Finally, I am concerned about how we will deal with failures of entire organisations and failure of services within those organisations before they reach a point where the welfare of patients is put into jeopardy.

Beyond legislation, Her Majesty’s Government need also to outline their strategy for implementation. It is fine that we have a Bill, but the two fundamental issues that need to be addressed will be the question of culture change in the NHS and the development of leadership to ensure that the changes necessary to protect and promote the interests of our patients are properly delivered.

Beyond culture change and leadership, I am also concerned that this Bill is subjected early to appropriate post legislative scrutiny. It is an important Bill with important consequences and I hope that a mechanism will be found to establish a committee that would follow this Bill, through its implementation, to determine that what was anticipated is actually achieved.

Healthcare has always been a highly charged and somewhat political issue. The birth of the National Health Service in 1946 was a highly political issue and every reorganisation since has been attended by controversy. Your Lordships’ House, however, has never felt it necessary to deny a health Bill a Second Reading, although in the health Bill in 2003, there was a vote at Second Reading. Nor has your Lordships’ House felt it necessary to send parts of a Health Bill to a Select Committee. It has always felt itself able, with its vast expertise ranging from previous Secretaries of State for Health, constitutional lawyers, current and former medical and other healthcare practitioners, regulators and those more broadly involved in public life to provide the necessary scrutiny for a health Bill. Indeed, I believe that the people of our country expect us to provide thorough, vigorous but thoughtful scrutiny of this Bill to ensure continued universal healthcare, free at the point of delivery, for all the people of our country.

Health: Non-communicable Diseases

Lord Kakkar Excerpts

Thursday 6th October 2011 Lords Chamber

[Lord Kakkar]

My Lords, I, too, join noble Lords in congratulating the noble Lord, Lord Crisp, on securing this important debate so soon after the United Nations summit on the problem of non-communicable diseases. In making my contribution, I remind noble Lords of my declarations of interest as professor of surgery at University College London and director of the Thrombosis Research Institute in London. Both institutions have active research programmes globally in the area of cardiovascular disease, the non-communicable disease that I will concentrate on.

As we have heard, non-communicable diseases now account for 63 per cent of all deaths—of the 57 million people who died in 2008. By 2020, some 52 million individuals around the world will die of non-communicable diseases. In 2008, some 25 per cent of the 57 million deaths were due to two important cardiovascular disorders: stroke and coronary artery disease.

We are making excellent progress in our own country in the management of patients with coronary artery disease and stroke. The national strategy addresses the 3 million of our citizens who suffer from cardiovascular disorders. That burden of disease was associated in 2006 with some 50,000 premature deaths in our country. It is estimated that by 2020 cardiovascular disease in the United Kingdom will be associated with some 58,000 premature deaths. Annually in our country, prescriptions for circulatory disorders cost the National Health Service some £2 billion. The total economic burden of direct and indirect costs associated with the management of cardiovascular disease in our country is estimated at some £30 billion a year. In the United States of America, the direct and indirect costs associated with the management of cardiovascular disorders come to some $400 billion a year.

It is in the developing world, in low and middle-income countries, that we see the fastest growth in cardiovascular disorders, one of the most important of all non-communicable diseases. Twice as many people in low and middle-income countries die of cardiovascular disease than they do of tuberculosis, HIV/AIDS and malaria combined. We can recognise the risk factors associated with the development of cardiovascular disorders in these developing countries. They are very similar to the risk factors that have been identified in our own population. High blood pressure, high cholesterol, lack of physical exercise, abdominal obesity, smoking and inappropriate diet are all important risk factors that can be recognised in these developing populations. As the noble Lord, Lord May, said, longevity ensures that populations are living longer in these countries, so they start experiencing cardiovascular disease.

The pattern of cardiovascular disease in low and middle-income countries appears to be quite different from the patterns seen in western countries. As we have heard, the onset of this disease is at a younger age in populations in India, in China, in Africa and in other important nations around the world. The pattern of disease in coronary artery disease, for instance, anatomically seems to be quite different, with disease more distally distributed in blood vessels, making it less amenable to the interventions that we provide for our patients successfully to treat coronary artery disease underlying coronary disease before it presents as a heart attack.

Of course, in addition to the pattern of disease and the early onset of disease, we also recognise in low and middle-income countries that the risk factors that are seen to be associated with the development of coronary artery disease are also associated with poverty in those countries. The high burden of cardiovascular disease in those countries is associated with increasing poverty in those populations.

If we look at the report by the World Economic Forum presented as part of the United Nations summit, we see that for low and middle-income countries over the period 2011 to 2025—a 14-year period—the economic loss to those communities associated with non-communicable diseases accounts for $7 trillion of lost economic output; for cardiovascular diseases it is some $3.76 trillion over that same 14-year period. That has huge impact in those nations in terms of avoidable economic burden.

If we look at this in terms of individuals, it is estimated that across Brazil, China, India, South Africa and Mexico, 21 million years of productive life are lost annually due to cardiovascular disease, a disease that is often attributed, as we have heard, to lifestyle choices, and of course to other environmental factors, but that is in many circumstances avoidable.

In driving economic benefit, therefore, there are important opportunities to be derived from targeting cardiovascular disorders and trying to promote strategies for prevention. Important public health strategies might be adopted around the world that could help reduce the risk of cardiovascular disease and its burden both for the individual and for society. Many of the strategies that have formed part of our national frameworks for targeting cardiovascular disease in the United Kingdom could usefully be adopted elsewhere in the world. We have heard during this important debate about the importance of prospectively collecting data to understand the distribution of risk factors for cardiovascular disease in low and middle-income countries, and in so doing better target our interventions that drive prevention on a population basis.

There are also some very exciting novel approaches to the prevention of cardiovascular disease at a population and an individual level. One of them is the concept of the polypill—identifying large populations and offering them; a pill that combines elements such as the statin that we have heard about from the noble Lord, Lord May of Oxford; aspirin, an agent that inhibits the activation of the blood cells in the circulation that come together to form small blood clots in the coronary arteries or the blood supply to the brain that result ultimately in a hard attack or stroke; an agent to drop blood pressure; and medications to control blood sugar. This polypill offered to populations, it is suggested, will reduce the impact of risk factors for the development of cardiovascular disease and therefore reduce the burden of that disease both clinically and, eventually, economically.

Another important approach is to target nutrition during pregnancy and in early life because it is well recognised that poor nutrition during pregnancy and in the first few weeks, months and years of life is associated with a heightened risk later in life for high blood pressure and the development of heart disease.

A third approach, which my own research institute is involved in, is the concept of vaccinating against atheroma, the disease pathology that was mentioned by the noble Lord, Lord McColl. The narrowing of the arteries is considered to be multifactorial, and there is some suggestion that an immunological response to the vessel wall as a result of chronic infection might play an important role in its pathogenesis, so vaccination across populations might be an alternative strategy to the prevention of cardiovascular disease. These are all novel ideas, with research being undertaken at many institutions here in the United Kingdom.

The research, whether conducted here and directed to populations elsewhere in the world, or conducted elsewhere in the world and directed to populations in our own country, is hugely important, because the burden of cardiovascular disease is a true global problem. In this regard, I ask the Minister what proportion of National Institute of Health research funding is directed towards the important problem of cardiovascular disease, both in improving the management for those with established disease and in the strategies targeted at risk identification and the development of biomarkers to understand better those at high lifetime risk for the development of cardiovascular disorders.

What proportion of our overseas aid budget is directed towards promoting research into cardiovascular disorders in low and middle-income countries? Potentially understanding the disease better in those nations, and therefore helping to prevent or treat it more effectively, could offer substantial economic benefits to those countries—benefits that are derived from such appropriate prevention and treatment of cardiovascular disease being directed to more beneficial areas of economic development.

Finally, I turn to the potential of using the Commonwealth—there was in your Lordships’ House some weeks ago a very interesting debate on the ongoing role of the Commonwealth—to develop a network between our own country and those with whom we have strong emotional and economic ties to pursue research into this important, chronic, non-communicable disease to determine whether that would both help us serve the people of those nations and ensure that nations on whom our own economic growth in the future is going to be dependent through export could avoid the economic and medical toll of cardiovascular disease.

NHS: Clinical Excellence Awards

Lord Kakkar Excerpts

Monday 27th June 2011 Lords Chamber

[Earl Howe]

My Lords, those who hold honorary contracts, who are in general clinical academics, are well represented among those who are awarded clinical excellence awards. We are absolutely clear that that should continue as long as possible. We must incentivise those who do not spend the bulk of their day engaged in treating patients so that we ensure that we have a bank of academic excellence driving forward innovation in the NHS.

[Lord Kakkar]

My Lords, what role do Her Majesty’s Government see for the academic health science centres in promoting clinical excellence? In asking the question I remind the House of my interest as a director of the UCL Partners academic health science centre at University College London.

Drugs: Prescribed Drug Addiction and Withdrawal

Lord Kakkar Excerpts

Thursday 23rd June 2011 Lords Chamber

[Earl Howe]

My Lords, the responsibility for commissioning these services in future will lie with local authorities, supported by Public Health England. The noble Baroness will be aware that it is our proposal to ring-fence the public health budget. Local authorities will be informed by the joint strategic needs assessment that they carry out and will work in partnership with local delivery organisations and with local GPs, who, as I have mentioned, will be even better informed than they are at the moment thanks to the Royal College guidance.

[Lord Kakkar]

My Lords, how much research into the problem of prescribed drug addiction is being supported by the National Institute for Health Research?

[Earl Howe]

My Lords, I am afraid that I do not have that figure in my brief, but I shall write to the noble Lord if it is available.

NHS: Waiting Times

Lord Kakkar Excerpts

Tuesday 3rd May 2011 Lords Chamber

[Earl Howe]

My Lords, first, referral-to-treatment times fluctuate. Having looked at how the figures have moved over the past year or two, my advice is that they are broadly stable. The figures to which the noble Baroness referred were struck at a particularly pressurised time for the NHS. As she knows, there are all kinds of reasons why during the winter referral-to-treatment times tend to lengthen. However, the right in the NHS constitution to be treated within 18 weeks remains. On accident and emergency waiting times, our clear advice from clinicians was that the four-hour target should be adjusted to reflect the clinical case mix and clinical priorities.

[Lord Kakkar]

My Lords, I am sure the noble Earl is aware of the recent report from the Royal College of Surgeons on emergency surgical standards. Does he share its concerns about the potential detrimental impact of waiting list targets for elective procedures on clinical outcomes for patients requiring emergency operations? In asking the question, I declare an interest as a practising surgeon and professor of surgery.

[Earl Howe]

My Lords, we are quite clear that timeliness remains an important ingredient in the care of patients. However, we are also clear that it is not the only measure of quality. On emergency surgery, there is no reason to expect that patients will be treated any less urgently in the future than they have been in the past. What matters is clinical priorities being set correctly.

NHS Reform

Lord Kakkar Excerpts

Monday 4th April 2011 Lords Chamber

[Earl Howe]

My Lords, when we went out to consultation on the White Paper last summer, concerns were raised that the transition could lead to too much disruption and a decline in the quality of services, as well as a loss of accountability, so the department decided to expand the approach to managed consolidation of PCT capacity and establish the clusters nationwide. That has been done already in London and the north-east and will pave the way for the NHS commissioning board to develop its roles. It will maintain accountability and grip during 2011-12 and the subsequent year, once strategic health authorities have been abolished. We are using existing legislative powers and it will help to oversee delivery in the coming two years.

[Lord Kakkar]

Is the Minister able to confirm that the future GP commissioning consortia will be constituted in such a way that they are obliged to conduct their responsibilities according to the Nolan principles?

NHS: Front-line and Specialised Services

Lord Kakkar Excerpts

Thursday 13th January 2011 Lords Chamber

[Lord Kakkar]

My Lords, like other noble Lords, I first congratulate the noble Lord, Lord Turnberg, on having secured this important debate and the noble Baroness, Lady Jolly, on a marvellous maiden speech, which was very moving. I also declare my own interest as a clinical academic practising surgeon and my role in the NHS Staff College at University College London Partners.

The question posed by the noble Lord in this debate is an important one. He asks what steps are currently being taken to ensure that front-line and specialist services are not undermined as we move towards the changes proposed in the forthcoming health Bill. Healthcare systems around the world, particularly mature healthcare systems, are all focusing on the need to improve quality and value, so that the very best clinical outcomes can be achieved for our patients and that these can be achieved in the most effective and cost-efficient fashion so that the valuable resources that the state provides for healthcare are used for the maximum benefit of all in society.

In that regard, there are four important actions that might be considered in the interim between now and when any changes that are finally agreed when the health Bill passes through this Parliament come into force. The first is in the area of the education of general practitioners and other clinicians in primary care who will have to play a greater role in commissioning. At the moment, there is no specific training for the skills that will be required to ensure that, at the very least, they can supervise and provide the appropriate governance for any commissioning taking place in the environments where they have responsibility in primary care. I ask the noble Earl what arrangements are being made currently to ensure that programmes of continuing professional development start to come into place to provide the skills to those working in general practice to prepare them for the new responsibilities that they will inevitably have if practice-based commissioning goes forward.

The second is an area that the noble Lord, Lord Turnberg, has alluded to—the whole question of integrated care pathways. These are important. In ensuring that we maximise quality and value in healthcare systems, it is well recognised that a focus on integrated care pathways, particularly for chronic diseases, will be essential. To ensure that we can provide the opportunity for informed commissioning of these services, we need to be certain that metrics that can be used to determine whether the clinical outcomes are successful and are providing best value are developed, assessed and then are available for those who will take commissioning decisions in the future. What arrangements are being made currently to start developing models of integrated care, particularly for chronic diseases? What work is being done to determine the appropriate outcome measures and metrics that might be used to drive commissioning decisions in the future?

The third area is one of specialist services and in particular the important question that has been raised about the tariffs and the current difference in costs for the provision of specialist services. With the move for responsibility for specialist commissioning to the NHS Commissioning Board, is work currently being undertaken to provide clear definitions of what specialist services will be in the future? For those delivered at regional or supra regional level, what will be expected of these specialist services? Is work being undertaken to determine what costs and tariff base will be required in the future to ensure that these specialist services are not undermined in the changed commissioning arrangements? In particular, will the institutions that provide these specialist services remain sustainable in the altered commissioning environment?

Finally, I turn to the issue of clinical leadership, one that I have spoken about previously in your Lordships' House. There is no doubt that that this is a major programme of change. It is often said that it is only those who deliver the service who can change the service. Our healthcare professionals, be they doctors, nurses or other healthcare professionals, will not be managed into this change: they will need to be led into it. Winston Churchill said some 60 years ago in a famous speech:

“Give them the tools and they will finish the job”.

I strongly believe that if we give our healthcare professionals effective clinical leadership, they will indeed deliver for us the change agenda of improving quality and value as well as these changes and those that the previous Government quite rightly focused on, so that we can continue to enjoy a National Health Service of which we are all proud, which delivers the very best healthcare for the people of our country.

NHS: Reorganisation

Lord Kakkar Excerpts

Thursday 16th December 2010 Lords Chamber

[Lord Kakkar]

My Lords, I, too, thank the noble Lord, Lord Touhig, for having secured this important debate and I declare my interest as a practising surgeon, clinical academic and chairman for clinical quality at University College London Partners Academic Health Science Centre.

The purpose of the White Paper and the health and social care Bill that will follow is good. It will ensure that the focus for the delivery of healthcare is very much on patients and on improving clinical outcomes. Those important principles are shared widely throughout the world and the proposals in the White Paper will ensure that the NHS gets to a position globally where it shows leadership in the quality movement, improved clinical outcomes and the efficient and effective use of resources, providing the very best healthcare for the people of our country.

Coupled with the proposals in the public health White Paper, there is the opportunity, if it is handled appropriately, to transform the healthcare experience for patients in our country and, more importantly, to start to focus resources in such a way that we maintain good health rather than continuously focusing only on treating patients, many with chronic disorders. The real question is how effectively we can take forward what is ultimately agreed, and therefore applied, to improve the outcomes and lives of our patients. That will require clinical leadership. It is regrettable that over so many years the National Health Service has failed to develop a sustainable mechanism to ensure that we can engage clinicians in leadership rather than just management. There is a very important distinction between the two.

One of the approaches in which I have been involved—I declared my interest in University College London Partners—is the establishment of the NHS staff college. It is modelled on the Army staff college. Indeed, we have engaged the faculty of the Army staff college to work with us in helping us to identify, through the self-reflection of those involved, and then to develop clinical leaders across the spectrum of primary care, including physicians, those working in secondary and tertiary care, managers and other healthcare professionals, to provide true leadership and ensure that the interests of patients and the utilisation of resource available within our healthcare system is applied effectively, to help these and other changes that may be applied for the benefit of the country. Will the Minister say what arrangements are being made and what strategy is in place to run in parallel with any changes proposed in the health and social care Bill for the sustained development of clinical leaders? That is a crucial issue, which warrants careful attention and appropriate thought to organise a leadership strategy that will help to deliver any changes that are finally agreed.

It is also well recognised that research and academic endeavour is hugely important to improving healthcare. Indeed, patients treated in systems where there is active research activity often tend to have better clinical outcomes. The academic health science centres have been discussed previously debate in your Lordships’ House in the excellent debate initiated by the noble Baroness, Lady Finlay, on academic health partnerships. The academic health science movement is now well established in our country. The issue with the proposed reorganisation is whether the focus on academic health—the partnerships that are required to ensure the leavening effect of academic medicine in improving standards across the entire system—will be sustained. That will require some careful thought in terms of the approach that the future NHS commissioning board takes on the nature of services and some of the innovative work that the academic health science centres can undertake, not only in improving outcomes and ensuring the best delivery for populations within their own remit, but as a test bed for ideas and innovations. By that I mean not only new treatments but new pathways of care that can be tested in the populations associated with the current academic health science centres. If proven effective, they can then be rapidly adopted throughout the National Health Service. Therefore, I ask the Minister whether there will be some opportunity to ensure that, in any discussions about the specific work and purpose of the commissioning board, the importance of academic medical research is well established and plays an important role in determining some priorities that the board may set.

Finally, I turn to education and training, which has been covered somewhat in the response on the White Paper that was published yesterday. We all recognise that the education and training of future generations of doctors—specialists, those working in primary care and those working in hospital practice—and allied healthcare professionals, who play such an important role in ensuring that we have effective teams, must remain a priority. From looking at the response, I understand that there will be further responses on education and training, which should be available shortly. However, there are concerns about the direction in which the education and training of a future workforce are going. Of course, it is well recognised that those commissioning local services will have a rightful interest in understanding what type of workforce—after a period of specialist training —will be available to look after the local healthcare needs for which they have commissioning responsibility. There must also be the opportunity to identify and set priorities at a national level for certain elements of very specialist training, to ensure that our country is able to offer the full range of healthcare that its people require. By that, I mean what is set at a local level and more specialist training, ensuring that we have the very best specialists to deal with some of the most complex problems. Therefore, it is important that education and training remain centre stage in all the decisions and discussions moving forward. I hope that the Minister can address that.

Health: Academic Health Partnerships

Lord Kakkar Excerpts

Monday 29th November 2010 Lords Chamber

[Lord Kakkar]

My Lords, I congratulate the noble Baroness, Lady Finlay of Llandaff, on having secured this important debate. I declare my own interest as a clinical academic and chairman for clinical quality at UCL Partners academic health science centre.

Healthcare systems around the world are facing considerable challenges. We know that in developing countries there is now an epidemic of diseases not previously experienced in those countries, such as diabetes, obesity, cardiovascular disease and so on. In our own healthcare system, we face similar challenges from chronic diseases that will need to be managed in an effective way, frequently with attention on prevention rather than just on treatment. We also still face serious disparities in access to healthcare, clinical outcomes, escalating costs for healthcare and variable quality across the healthcare system, as we have seen this past weekend with the publication of the Dr Foster report on adverse events experienced throughout the healthcare system in England.

Over the past 50 years, many of the advances that have helped us to improve outcomes and the quality of care that we provide to patients have been academically led. There is a growing recognition that the contribution of academic medicine is potentially even greater now than in previous decades because the challenges that we face are much greater. As we have heard, there is a developing movement throughout the world, certainly in mature healthcare systems, for the development of academic health science centres, which are well placed to face the challenges that have been identified as the pathway of discovery care. That continuum needs to be bridged to ensure that research activity, stimulated by endeavour, careful thought and intellectual enterprise, can be converted into new interventions, therapies and systems and into pathways of healthcare to improve clinical outcomes.

It is now well recognised that there are two important gaps that academic medicine and institutions can overcome in this discovery care continuum. The first is the gap characterised as “from bench to bedside”, taking those discoveries and having appropriate translation medicine to ensure that those discoveries can be tested and presented to the wider clinical audience—clinical colleagues and other healthcare professionals, as we have heard—in such a way that they might be adopted to improve clinical care and outcomes.

The second gap is to move from a very difficult place where there is expert acceptance of the discoveries and their evaluation from basic and clinical research, and to ensure that those are broadly adopted. Indeed, it is quite shocking—here I must declare a further interest as director of the Thrombosis Research Institute in London, which is involved in many collaborative research programmes with industry in the area of thrombosis—that this weekend we saw, in the Dr Foster analysis of adverse events in our healthcare system, some 62,800 reported adverse events, 30,500 of which were deep-vein thrombosis or pulmonary embolism. That is quite striking as we have known for over 30 years, thanks to research, much of which was conducted in the institute that I am now director of, that there are simple ways to assess patients at risk of thromboembolism and simple methods that can be applied to those at risk to reduce their risk of developing a blood clot while in hospital or soon after being discharged. It is well recognised by experts. We have guidelines. Indeed, we have the active programme from the Department of Health in this area. There is still a gap, however, in its widespread adoption. I very strongly believe that academic health science systems have an important role to play in overcoming this gap and ensuring that what we understand can be applied not only in single institutions but broadly across healthcare systems to improve clinical outcomes, and in ensuring that the research effort is properly applied to benefit the largest number of potential patients.

We have also heard that there are important economic benefits to be derived from having a strong academic clinical base. One of the purposes of the five academic health science centres, which we have heard about previously in this debate, is to ensure that the United Kingdom remains an important target for inward investment by the bio-pharmaceutical industry for research and that the opportunity to collaborate with industry delivers not only clinical benefit for our patients but economic benefit for our country.

Will the Minister confirm—I am sure this is the case—that academic health science centres remain at the very heart of Her Majesty’s Government’s agenda for healthcare and ensuring that we can achieve the very best clinical outcomes, quality, access and value in our healthcare system? Will he also confirm that the opportunity will be taken to explore whether the remit of academic health science centres can be explored so that they focus much more on becoming academic health science systems across entire sectors or health economies, driving the potential for broader integration—both vertical integration across primary, secondary and tertiary care, and horizontal integration, as we have done at UCL Partners—in developing provider networks that are focused not on the outcomes that an individual institution can achieve but on the outcomes that are achievable across the entire patient pathway and are focused on improving clinical outcomes for the continuum of care, particularly for the management of patients with chronic conditions? Will he also confirm that we will look at how academic health science systems can facilitate primary care commissioning as that moves forward and is developed in the coming years, and that we will continue to ensure that the contributions that the United Kingdom can make globally to academic health science systems and centres are maintained and that our country continues to benefit from participation in those systems and centres?

[Lord Butler of Brockwell]

My Lords, I, too, thank the noble Baroness, Lady Finlay, for the opportunity to discuss what I think is a very exciting and positive feature of our national scene: the partnership between academic and health activity. It is also a pleasure to follow my noble friend Lord Kakkar, whose professional interests, as he has explained, lie in north London but whose personal interests lie, like mine, in south London.

The question asked by the noble Baroness, Lady Finlay, is how the Government propose to preserve academic health partnerships. I should declare an interest as chair of King’s Health Partners, one of the five national AHSCs about which the noble Baroness, Lady Donaghy, has already spoken so fluently. Indeed, I endorse everything that she said. The noble Baroness, Lady Finlay, was right to emphasise the great advantages that Britain has in contributing academic research to medicine and how this country punches above its weight in those areas. As the noble Lord, Lord Kakkar, said, this is not only a benefit to health treatment but an enormous economic benefit through the investment of big pharma in this country. Perhaps that investment is second only to financial services in its importance to the economy of the country. But it is fragile, and we have already seen some signs of that fragility with GSK’s decision to move many of its activities to Shanghai and Merck’s departure. We must strive to maintain this country’s attraction for big pharmaceutical companies. It is very reassuring that the Government recognise that. The emphasis on the importance of research in the Government’s White Paper is also greatly welcome.

As other speakers have said, the five AHSCs are among the most valuable instruments for bringing together academia and the National Health Service, which might, as the noble Lord, Lord Alderdice, said, have drifted away from each other somewhat in the past 15 years. I pay tribute to the steps that the previous Government took to reverse that trend, not least by establishing the AHSCs. To reflect on the partnership with which I am associated, what does that partnership bring together? In King’s College London, it brings an outstanding research university and a leading medical training institution; in Guy’s and St Thomas’ and King’s College Hospital, it brings two of the world’s leading teaching and clinical care hospitals; and in the South London and Maudsley Hospital, it brings one of the nation’s leading psychiatric hospitals.

I invite the House to consider what we can achieve in modern healthcare by closer links between those institutions. First, as has been mentioned, we can bring research and clinical care closer together, and accelerate the translation of the very exciting discoveries that are made all the time in research to the care of the patient.

Secondly, there can be a closer link between mental and physical care. I particularly emphasise this in the case of the partnership with which I am associated. It is a weakness of our present system that psychological morbidity in patients with physical illness and physical morbidity in patients with mental illness have not been sufficiently recognised and addressed.

Thirdly, there are the integrated pathways of care for patients. This is, I think, very close to the Government’s heart and their policy in the White Paper. Like the other two London AHSCs, King’s Health Partners is working with local GPs and local authorities to establish new models of preventive medicine and community care, as well as tertiary care.

Finally, there can be more effective medical training not only through the university and teaching hospitals but in the community through the health innovation and education cluster—the HIEC—for which King’s Health Partners has been given the lead for south London.

This link between research and clinical treatment is personified in the chief executive of King’s Health Partners, Professor Robert Lechler. He is not only a distinguished researcher and clinician at Guy’s Hospital but vice-principal of the university. This link is repeated in many others who hold joint appointments in the university and member hospitals. The challenge for the AHSCs is to realise the opportunities that these existing links represent.

As has been mentioned, the previous Government, in setting up the AHSCs, did not give them any extra funds, unlike the Dutch Government, who recognise the importance of their equivalent of AHSCs through higher-intensity payments for them. Despite the lack of a financial incentive, when I came into this work, I, like others who have spoken, was hugely impressed by the enthusiasm and commitment not only of the four partner institutions in the AHSC with which I am associated but also—again, this has been mentioned—among the world-renowned researchers and clinicians who form part of them. This really is a movement that is supported at the grassroots level by those who work in the field. Like others, I hope the Minister will be able to say tonight that the Government endorse the objectives that I have described and see AHSCs as crucial to achieving them.