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.

Medical Profession (Responsible Officers) Regulations 2010

Lord Kakkar Excerpts

Tuesday 23rd November 2010 Lords Chamber

[Lord Kakkar]

My Lords, we have heard that the key priority of the General Medical Council for patient safety and ensuring continuing standards and confidence of the public in regulation is the process of revalidation. We have heard in the Chamber today very strong support for the regulations.

The early appointment of responsible officers is critical. It will ensure that the system can be tested. The noble Baroness, Lady Thornton, was absolutely right to raise the structure in which responsible officers in the area of primary care will eventually be able to operate, but this matter can be dealt with when the health Bill is laid before Parliament and the primary care structures in it can be appropriately scrutinised.

As we have heard, if the regulations are in any way derailed at this stage, there is a danger that the whole momentum of revalidation will be disrupted. It could cause anxiety in the profession and lead to unhelpful pockets of resistance. There is now an ideal opportunity for a mechanism and the early appointment of responsible officers to test potential systems and determine where the weaknesses are. This will occur before revalidation comes into force in its fullest form, and will therefore allow the General Medical Council to respond appropriately. I add my voice to those of many noble Lords in supporting the regulations.

[Lord Colwyn]

My Lords, although the principles behind revalidation, which aims to raise confidence in clinical standards, are welcomed, there are concerns over the ways in which the Department of Health plans to implement the process through the responsible officer regulations. There is also concern about the new regulations coming into force in January 2011, given the proposals in the recent health White Paper to abolish structures that were intended to support the role.

I agree with the noble Baroness, Lady Finlay, that the demands of the role outlined in the proposals will require a person of quite exceptional skills and competences. It is assumed that many medical directors will become responsible officers, which will significantly extend their role by extending their responsibility, powers and workload.

There is already a marked variation in the abilities of medical directors to investigate performance concerns and implement local disciplinary procedures. The additional duties are likely to be onerous. It is not certain that senior doctors with the necessary professional standing will be willing to take them on, or that it will be possible to find senior doctors with the necessary standing and experience to succeed in this role.

It is essential that adequate resource is allocated to support responsible officers and that they are appropriately equipped to carry out their responsibilities. The guidance to the draft regulations emphasises that there must be a “robust” medical management infrastructure to support the responsible officer and sufficient delegation of duties to enable the role to be delivered to a high standard. How will this work in practice and how will it be resourced?

The draft regulations do not reflect the changes proposed in the White Paper. Reference is made throughout to “designated bodies”. These include PCTs and SHAs, which are to be abolished by 2013. There is no detail on what structures will support responsible officers, revalidation and other aspects of performance management in primary care after 2013. This makes the decision to press ahead and appoint 975 responsible officers to strengthen systems in structures that are to be abolished difficult to understand. Surely, given the decision to delay revalidation and the uncertainty around the structures that will support performance management, more time is needed to pilot and evaluate the responsible officer system effectively before bringing these measures into force in January.

NHS: Prebiotics

Lord Kakkar Excerpts

Wednesday 17th November 2010 Lords Chamber

[Earl Howe]

My Lords, I merely meant to indicate that we would welcome good-quality proposals. On probiotics, I understand that one study using live yoghurt showed a patient benefit but my advice is that the study methodology was flawed and its findings were not generalisable. Probiotics are not therefore recommended, as studies have failed to show any convincing evidence that they either treat or prevent C. difficile infection.

[Lord Kakkar]

My Lords, is the noble Earl concerned about the presence of the potentially more aggressive and resistant forms of C. difficile that have been identified in our hospitals? What action is being taken to ensure that they do not spread more widely?

[Earl Howe]

My Lords, the noble Lord is absolutely right. It is appropriate for me to emphasise that, as he will well know, inappropriate prescribing of antibiotics is above all what has caused the high levels of infection that we have seen in recent years. The use of broad-spectrum antibiotics predisposes people to C. difficile infection, so it is important that those in the health service understand the cause and effect relationship involved.

It is also worth mentioning that tomorrow is European Antibiotic Awareness Day, so it is appropriate that this Question has been asked today.

Healthcare: Costs

Lord Kakkar Excerpts

Monday 15th November 2010 Lords Chamber

[Earl Howe]

The noble Baroness is quite right, and I am well aware that she speaks from personal experience. Many hospital trusts, and indeed GPs’ surgeries where applicable, have devised inventive ways of reminding patients of their appointments, either on the day or on the day before, perhaps by text. Good practice in this area is something that we need to focus on.

[Lord Kakkar]

My Lords, clinical leadership is critical if we are to secure the greatest benefit for patients from NHS spending and the appropriate use of resources. What strategies do Her Majesty's Government have for developing clinical leadership in the NHS? I declare an interest as patron of UCL Partners’ NHS staff college.

[Earl Howe]

Again, my Lords, the noble Lord is absolutely right to focus on clinical leadership, which will be critical if we are to deliver the improvements in the quality of care that we wish to see, and also to roll out the vision laid out in the Government's White Paper. The department has a number of initiatives under way, as do deaneries in strategic health authority areas around the country, to promote clinical leadership. There are also active programmes in acute trusts. Without good clinical leadership, the programme cannot proceed as we all hope and wish.

Genomic Medicine: S&T Committee Report

Lord Kakkar Excerpts

Wednesday 9th June 2010 Lords Chamber

[Lord Kakkar]

My Lords, I, too, congratulate my noble friend Lord Patel and members of the Science and Technology Committee on this excellent report. I was not a Member of your Lordships’ House when the report was first published but I have had the opportunity to speak to my noble friend about its recommendations, and I agree with my noble friend Lord Sutherland of Houndwood that the implications of the report will be read throughout the world. It is a thorough, thoughtful and authoritative piece of work, and I am sure that many other Governments and authorities will wish to consider its recommendations as they consider an issue that will affect the provision of healthcare throughout the world.

The advances in genomic medicine that we have heard about in this debate are profound and, as we have heard, are starting to affect clinical practice today in the management of common diseases. There is no doubt as we move forward that the research that is being undertaken in this country and in other parts of the world will start to resonate, in terms of both what is available for our patients and what our patients and the general public hear about. This will drive patient and public expectation. We have heard that genetic testing and new diagnostic strategies will be available, not only through mechanisms provided through the National Health Service and other care institutions, but, as we have heard, will be available independent of healthcare institutions and systems. This will pose a considerable challenge for medical practice. Medical practitioners will be keen to do the very best for their patients and respond to their inquiries, but they will not be able to do that if they are not trained and educated in the new science of genomic medicine.

I shall concentrate on the issue of the recommendations in chapter 7 of the report—those related to education, training and workforce planning. If we do not get this right, many of the potential advantages and benefits that we could potentially provide to society will be lost in the medium term, and in fact there will be opportunities for misunderstanding as the available science is misunderstood and clinical practitioners are not able to respond.

Some important areas have been identified in the report regarding the question of primary education, subsequent training and continuing professional development. With regard to undergraduate medical education, the General Medical Council, in its publication Tomorrow’s Doctors, which was updated in 2009, has recognised the importance of including a requirement for the teaching of genetics in the curriculums offered by higher education institutions in the United Kingdom offering primary medical qualifications. There is no doubt that these will be adopted because the recommendations in Tomorrow’s Doctors will have to be applied by 2011-12, so we can feel certain that new generations of medical students moving into the next stage of their training will have knowledge about this important new science and will therefore be ready in their subsequent training to learn how to apply it.

We need to be certain that those training programmes both for primary and secondary care across the disciplines and sub-specialties have a requirement to ensure a core competency in the understanding of genomic medicine as it applies to that specific discipline. That has been agreed in terms of the Government’s response, but we need to make certain that it is applied. The coming together of the General Medical Council and the Postgraduate Medical Education and Training Board certainly suggests an opportunity for that to happen. I hope that the noble Earl will confirm that this will remain an area of focus so that the training we provide ensures the opportunity for practitioners to be able to respond not only to knowledge currently available but knowledge that will become available in the near and medium-term future. As we have heard in this debate, so much research is taking place in this particular area that advances will come thick and fast.

Then there is the issue of current practitioners—a very large proportion of the workforce—who were educated and undertook their training prior to the whole emergence of the field of genomic medicine. They will be seeing patients and members of the general public with the results of tests and inquiries about the implications of genetic and genomic medicine on their own health day in and day out, but they have not been trained to date. We need mechanisms for continuing professional development that ensure that as advances become available, and are being considered by our healthcare systems, they can be readily made available to practitioners so that they are able to respond to inquiries from their patients. That will be hugely important because large numbers of doctors and other healthcare professionals will be confronted with these challenges. We need to make sure that we have considered this and that we have appropriate mechanisms available to ensure that continuing professional development also provides opportunities as we go forward.

If we do not do that, the advances that come from all the excellent research and technology that we have heard about will not be readily available to patients as soon as we would hope. That will cause anxiety and unhappiness. It will miss opportunities in terms of protecting people and providing early opportunities for diagnosis and better treatment outcomes. Therefore, I urge the Government to look at this whole area of training and education in terms of taking forward the excellent recommendations in this report.

Queen's Speech

Lord Kakkar Excerpts

Thursday 3rd June 2010 Lords Chamber

[Lord Kakkar]

My Lords, it is with great humility that I beg your indulgence on this, the first occasion on which I address your Lordships’ House. In the few weeks since my introduction, interrupted by the general election, I have enjoyed the warmest of welcomes from so many noble Lords and Baronesses, for which I am most grateful—as I am for the courteous, kind and thoughtful help that I have received from numerous members of staff, including the Clerks and the dedicated Doorkeepers. My happiness in making this speech is tempered by thoughts for Black Rod, who was particularly kind to my family at my introduction and whom I have had the chance of seeing, most recently yesterday evening, in hospital. I know that all our thoughts are with him and his family.

I also express my particular thanks to my supporters: the noble Lords, Lord Higgins and Lord Patel, and the Convenor of the Cross Benches, the noble Baroness, Lady D’Souza.

I could not let this occasion pass without recognising the role of the House of Lords Appointments Commission in my being here. Its thorough interrogation to which I was subjected was without doubt the most demanding and insightful of my professional career to date.

My emotions always run high as I enter the House. I never cease to be amazed by the history that attends our deliberations and the vital role that your Lordships play in ensuring that potential legislation enjoys rigorous scrutiny, so that the best possible laws may join the statute book for the benefit of all our people. That this important work is conducted in such a decent, thoughtful and selfless fashion, calling upon a wide range of scholarship, expertise and, above all, experience, makes this House truly unique.

Nor do I cease to be amazed that I find myself among your Lordships, something I could never have imagined on 7 December 1977 when, as a schoolboy, I made my first visit to this House, on which occasion I was filled with awe, excitement and a passion for our nation’s democracy, debate and political discussion. The educational outreach programmes conducted by your Lordships are invaluable, and I hope to be able to contribute to these to help enthuse future generations of schoolchildren about the important work of your Lordships and about what is done in this House and how it forms a cornerstone of our much cherished democracy.

My professional life outside your Lordships’ House is as professor of surgical sciences at Barts and The London School of Medicine and Dentistry, part of Queen Mary College in the University of London, and consultant surgeon to University College Hospital. I also have the privilege to be director of the Thrombosis Research Institute in London, a world-leading centre dedicated to better understanding the problem of blood clots and how best they can be prevented and treated.

In the practice of medicine and my interest in thrombosis, I follow my father, a professor of surgery, and my mother, an anaesthetist, who came to our country in 1961 to complete their medical training. They were part of a substantial wave of immigration from India made possible because of a national consensus, long held, that has ensured opportunities and advancement for immigrant communities willing to integrate and contribute broadly to British society. What excitement there must now be among all British citizens of Indian origin on learning in the gracious Speech about the Government’s desire for enhanced partnership with India, a wonderful opportunity for this vibrant community to contribute to securing broader opportunities for the entire nation.

In many ways, consensus and institutions define our national character. It is about one of our great national institutions, the one in which I continue to have the privilege to practise as a surgeon and about which I must therefore declare my interest—the National Health Service—that I would like to speak to your Lordships today. Like any great institution, the NHS cannot and must not be taken for granted. It needs to be nurtured, nourished and pruned thoughtfully and sensitively where necessary but, above all, respected.

The gracious Speech indicates the Government’s desire to enhance the voice of patients and strengthen the role of doctors in the National Health Service. These are indeed important ambitions, and are made recognising the nation’s serious fiscal challenge, a situation that will dominate the way that all public services can be delivered for years to come.

Time and again, Governments have felt an obligation to turn to the question of NHS reform. Why is this necessary despite substantial investment, a dedicated and talented workforce and its unique place in the nation’s affections? Why is it that the care received by patients, and their experience of it, varies so considerably; that patient safety and dignity can still regularly be jeopardised; that we have not been able to define models and pathways of care that successfully cross the barriers of the hospital and general practice environment; that we are still witness to some shocking inequalities in health, none more so than those experienced by the homeless; that we have failed to develop a sustainable public health strategy; and that we are often unable to successfully disseminate and rapidly adopt innovation and the findings of medical research for the benefit of our patients? So much has been achieved, yet there is so much more that we need to do if we are to retain a sustainable National Health Service for the benefit of all. The nation’s continuing commitment to the NHS offers both opportunities and important challenges to the medical profession.

All life is a journey, and in my own as a clinical practitioner and academic I have learnt so much about the dignity and resilience of human beings, but also about their frailty and insecurity. It is with this in mind that individual practitioners must deliver healthcare, at a time when both patients and relatives are at their most vulnerable. Beyond the delivery of care to our patients, however, clinicians will have to direct their current skills, and develop new ones, to help ensure that the very best possible gains in public health can be achieved, and that we facilitate the most effective use of the public funds available for healthcare to deliver maximum societal gain.

This is an impressive challenge, but one with which my own profession must fully engage, and I am sure it will, through providing clinical leadership. Indeed, in its report, Future Physician: Changing Doctors in Changing Times, the Royal College of Physicians of London recognises this to be a critical issue and an obligation for the medical profession. However, there is an important distinction between leadership and management in the NHS, a distinction that needs to be clearly understood so that the development of true leaders across both primary and secondary care can become enshrined in the way that we nurture the careers of our most able clinicians.

Leadership is never easy, and clinical leadership will require healthcare professionals to engage with difficult decisions. How can resources be most efficiently utilised? How can the delivery of care be safe and effective while always ensuring that patients are treated with dignity and humanity? How do we ensure that advances in medical research and innovation, once proven, are rapidly adopted for the benefit of our patients, communities and society more broadly?

To effect change, partnership will be essential—partnership between patient and doctor, academic and clinician, hospital doctor and general practitioner, and of course Government and healthcare professional—always focused on the best that we can achieve for our patients while working to ensure that the precious and generous funding available for healthcare provides maximum benefit.

Despite being one of our country’s most cherished and important institutions, the NHS, like all healthcare providers around the world, faces immense challenges. With ever increasing costs on the one hand, and both the delivery of care and the nation’s health failing to meet expectations on the other, courage will be required to secure a sustainable NHS for the benefit of our people. The forthcoming health Bill offers the opportunity to ensure clinical leadership and partnership within the NHS. The expertise of your Lordships’ House will play an important role in achieving that. I thank noble Lords for having given me the opportunity to speak.