Long-term Plan for the NHS

Lord Kakkar Excerpts

Tuesday 19th June 2018 Lords Chamber

[Lord O'Shaughnessy]

The noble Lord speaks with great insight and makes a very important point. There is broad agreement on the need to simplify the structure of the health system but there has not to date been broad agreement on how we should do so. We are expecting in the next few months to explore the potential for the kind of streamlining that he is talking about. I hope that that can be done as a collaborative effort and, if it comes to primary legislation, that we can deliver it as a collaborative effort too.

[Lord Kakkar (CB)]

My Lords, I declare my interest as chair of University College London Partners Ltd. Although this substantial increase in funding has quite rightly been welcomed, important questions remain. It is essential that real progress is made in integrated care—integrated care between the community and secondary and tertiary sectors, and integrated care between hospitals and social care. It is vital that progress is made in the rapid adoption of innovation at scale and pace across entire health economies. It is also vital that a programme is put in place to ensure that there is a transformation of the healthcare workforce so that those who have committed themselves to being healthcare professionals can continue to be developed and serve their fellow citizens across an entire professional career. How do Her Majesty’s Government propose to achieve this? There has been much good intention and great commitment in this area over the past two decades, but we are now at a critical moment where a failure to deliver the transformation required will result in failure to achieve the long-term sustainability to which we are all committed.

[Lord O’Shaughnessy]

The noble Lord makes excellent points. It is right at this moment to applaud the wisdom and far-sightedness of the Lords Select Committee on the long-term sustainability of the health and social care system. It called for, among other things, funding of growth in line with GDP, delivering integration, a 10-year workforce strategy, a commitment to reduce variation and a joined-up Department of Health and Social Care, all of which, if we were not able to deliver it in time for our response to the report, we are delivering in short order afterwards.

One of the first ways in which we shall do it is to draw on the wisdom that resides in the NHS, in Parliament and elsewhere in the profession. In the Statement given by my right honourable friend, I point again to the commitment to take on integrated care, that being one of the tests of success. Equally, there is the commitment to transformation of the workforce, to make sure not just that we have enough people but that we have enough flexibility and digital skills, for example.

The final point, on innovation, is very close to my heart—and indeed the Secretary of State’s. We know that doing things in the same way will not deliver the standards we need. We really need a transformation in how we deliver healthcare, much greater digitalisation of the entire sector and the ability to take the amazing innovations that we develop in our laboratories and universities, such as the noble Lord’s own, and get them into use across the NHS. That is one reason why I was so delighted that we were able to announce today that the noble Lord, Lord Darzi, will be chairing our Accelerated Access Collaborative. It is hard to think of anybody more committed to this agenda than him.

NHS: Artificial Intelligence

Lord Kakkar Excerpts

Tuesday 24th April 2018 Lords Chamber

[Lord O’Shaughnessy]

Yes, I absolutely agree with that. As the report highlights, we have a unique opportunity because of the nature of the way that the NHS was set up and its potential for realising a comprehensive data set of 65 million people. It is not just about those procurement rules; we have talked about having the right framework. It is about providing reassurance within the system—at a time when the public are beginning to understand just what data can do for good and for bad—that the NHS will use their data safely, securely and legally so that they can trust that it is being used for proper purposes from which they will benefit.

[Lord Kakkar (CB)]

My Lords, I declare my interest as chairman of University College London Partners. Does the Minister believe that there is a sufficiently robust mechanism for the diffusion of the innovation associated with digitalisation and artificial intelligence across the NHS? In particular, what role does the Minister think the academic health science networks should play in that process?

[Lord O’Shaughnessy]

Of all the innovations, diffusion is probably one of the greatest challenges that the NHS faces, as the noble Lord knows very well. We are doing a couple of things. First, we are supporting the global digital exemplars, which are providing that digitalisation at trust level, to make sure that they have the infrastructure there. Secondly, he talks about academic health and science networks. They have just been relicensed and are now to have a national remit to promote innovation. AI is absolutely part of the work that we are expecting them to do.

Public Health: Strength and Balance Programme

Lord Kakkar Excerpts

Thursday 18th January 2018 Lords Chamber

[Lord O'Shaughnessy]

Indeed it is, as are other things such as yoga, tai chi and—believe it or not—carrying shopping bags.

[Lord Kakkar (CB)]

I declare my interest as chairman of University College London Partners. What assessment have the Government made of the provision of accountable care organisations to drive the integration across primary care, secondary care and social care to achieve the kinds of objectives that are the subject of this question?

[Lord O'Shaughnessy]

The noble Lord makes an incredibly important point. We know that we want an integrated health service, particularly as we have older people with comorbidities using a range of services. The five-year forward view—NHS England’s own strategy for the future—talks about how that integration will take place through what the noble Lord calls accountable care organisations or systems. We are moving ahead with these: indeed, the most recent Budget is providing significant capital to support that integration. This is the future of the NHS, and we all need to get behind it.

NHS: Wound Care

Lord Kakkar Excerpts

Wednesday 22nd November 2017 Lords Chamber

[Lord Kakkar (CB)]

My Lords, I too congratulate the noble Lord, Lord Hunt of Kings Heath, on having secured this important debate, and the noble Baroness, Lady Wheeler, on having introduced it in such a thoughtful fashion. I declare my own interests as professor of surgery at University College London, chairman of University College London Partners and director of the Thrombosis Research Institute in London.

As we heard from the noble Baroness, some 2 million individuals suffer wounds every year—one in 20 of the adult population of the United Kingdom. That is a substantial clinical burden in itself, but beyond that we have heard about the pressures that puts on the NHS. Some £5 billion is spent on this every year—a similar financial burden to that involved in NHS management of obesity. There is, rightly, great emphasis on the problem of obesity but very little on understanding how we can avoid and, when they occur, best manage, chronic wounds sustained by health service patients.

Beyond our understanding of the clinical burden and the cost to the NHS, there is a broader economic burden that we do not talk about: lost productivity of individuals who could otherwise be making an important contribution to the economy. Regrettably, our understanding of that is poor when looking at the broader implications of chronic conditions in the National Health Service.

Guest and colleagues, publishing in the British Medical Journal in 2015, provided a detailed analysis of this cost burden on the NHS. Some £320 million was attributable to general practitioner visits; £920 million was associated with nursing visits in the district; £415 million was spent on out-patient visits, and some £1.2 billion was associated with hospital admission. Some £170 million was spent on the use of diagnostic tests associated with wounds, £260 million on the use of medical devices, £740 million on wound care products, and £1.2 billion on prescription drugs. So it really is a substantial burden.

I shall focus my remarks on three areas—chronic venous ulceration, diabetic foot ulceration and pressure ulcers—to try to understand Her Majesty’s Government’s approach to prevention in any national strategy for the management of wounds. It is clear that prevention is always better than having individuals sustain a particular complication; therefore, a prevention strategy should be at the heart of any national strategy on the management of wounds. I should declare a particular interest when I speak about venous ulcers; they are principally associated with a failure to prevent venous thromboembolism, which is one of my major research interests. A strategy directed at preventing venous thrombosis in hospitals would eventually be associated with a substantial reduction in the frequency of the post-thrombotic syndrome, one manifestation of which is chronic venous ulcers. An important element of that strategy is already in place—mandatory risk assessment for thrombosis for patients coming into hospital—but as part of a broader wound strategy, that would clearly be an important area.

An important element of prevention of the chronic wounds resulting from diabetic foot ulceration is screening for diabetes before complications become apparent, as well as the appropriate and fastidious management of diabetics so that they do not go on to develop ulcers. If they do develop ulcers, careful management and assessment are necessary to ensure that the ulcers can be treated and heal quickly or that they are effectively managed to prevent the kinds of complications we see, particularly amputation.

Then there are pressure ulcers in immobile patients confined to bed, not only in hospital but at home. These are very serious problems but careful attention to nutrition and to cardiovascular and non-cardiovascular comorbidities, which can affect the circulation, will provide an important opportunity to prevent, or ensure more effective management of, pressure ulcers.

Pressure ulcers are a particularly interesting problem; we see substantial numbers of them in the NHS. Regulation 12 of the CQC standards when inspecting hospitals for quality assesses in institutions measures to both prevent and manage pressure ulcers. As a result, as part of the NHS safety thermometer, we see regular reporting of the frequency of pressure ulcers in different healthcare institutions. It is striking that in August of this year, the thermometer showed that 4% of patients in institutions had a pressure ulcer; but looking at the most recent thermometer, for October, the figure is between 0.6% of patients in one institution and 7% in another. This variation seems quite remarkable and is clearly unacceptable. There are important lessons to learn across institutions to ensure that best practice is applied across the entire NHS to reduce the frequency of these important complications.

We have to recognise the risk to patients of developing chronic wounds when their care is managed in the community. Those patients are often neglected and not always assessed as part of the overall burden of disease in terms of pressure ulcers. It is anticipated that about 5% of patients being managed in their own home will have pressure ulcers—again, a substantial number of individuals.

There is very good evidence that if best practice and guidelines are properly applied, and if they are integrated into a national strategy and applied more fastidiously, there could be an important impact on reducing the burden of these problems. Initiatives in the Midlands and the east of England with regard to application of Royal College of Nursing and NICE standards on the management and prevention of pressure ulcers resulted in a 50% reduction in their incidence in associated healthcare environments in those regions in the first year after application. Similar impressive results have been seen in care homes in Sutton as part of a community care vanguard in that region.

Clearly, prevention is validated and should play an important role in any national strategy. If they proceed with a national wound management programme, do Her Majesty’s Government believe that prevention should be at its heart and that best practice and prevention should be broadly promoted and adopted at scale and pace through various health economies in hospital and in the community? Secondly, what assessment have they made of the remarkable variation in the frequency of pressure ulcers? I was not able to find data pertaining to other forms of chronic ulceration, such as venous or diabetic ulceration, but I suspect there must be substantial variation. What assessment has been made of such variation in clinical outcomes? Thirdly, I would like to understand how they propose to address that variation. Such variation exists throughout the NHS but this area, with such a large clinical and economic burden, needs to be one of priority. Finally, what advice has the Department of Health given to the National Institute for Health Research in trying to identify opportunities for more research in this area to advance clinical practice?

National Health Service

Lord Kakkar Excerpts

Tuesday 10th October 2017 Lords Chamber

[Lord O'Shaughnessy]

The noble Baroness asked a few questions that I will try to deal with. First, on new models of care and STPs: STPs are now being ranked in order to see their fitness for moving forward. The Chancellor announced in the Budget that we will invest £325 million initially, with more funding in the future to support the transformation that we all want to see. The noble Baroness is right to point out that our care model is still based around hospitals and curing infectious diseases, rather than dealing with chronic illnesses and comorbidities. That needs to change.

I echo, as the noble Baroness would, the Care Quality Commission’s report, which talked about staff dedication—nowhere is that more true than in mental health, where staff often deal with very difficult circumstances. It is important to talk about that on World Mental Health Day. She may be interested to know that the Cabinet was briefed today by mental health experts about training programmes going into schools, and so on. There is a lot of work going on, but these are the NHS’s own plans for change, which this Government are backing.

[Lord Kakkar (CB)]

I speak as Professor of Surgery at UCL and chairman of UCL Partners. It is widely accepted that innovation is essential to ensure NHS sustainability. Are Her Majesty’s Government satisfied that there is sufficient emphasis on and support for NHS England in driving types of innovation, such as therapeutic innovation—both in models of care and working practices—that will achieve long-term sustainability?

[Lord O'Shaughnessy]

The noble Lord makes an excellent point. It is true to say that in this country we are very good at creativity and innovation but not always very good at spreading it round. In a way, that is one of the biggest challenges the NHS faces. I would merely highlight a couple of areas where the NHS is working well. The first is the test beds programme, which is working with industry, taking new innovations and spreading them round. Secondly, we have committed to publishing our response to the accelerated access review by the end of the month on how to make sure the most transformative drugs, devices and therapies are taken up throughout the system.

Mental Health and NHS Performance Update

Lord Kakkar Excerpts

Monday 9th January 2017 Lords Chamber

[Lord O'Shaughnessy]

I am grateful to my noble friend for his kind words of welcome. On the specific issue raised on the “Today” programme, which I believe is the subject of a documentary, and how it relates to the Statement made by my right honourable friend, there is an important distinction, which is that it is at the discretion of local clinical leaders. It is not a blanket mandate to delay treatment where the ethical and clinical responsibilities of those treating a given patient require it to be done speedily.

On the issue of the workforce changing, I take my noble friend’s point about what in the education world we called FTEs—full-time equivalents—and will make sure that the workforce figures I use are always expressed in those terms.

[Lord Kakkar (CB)]

My Lords, I declare my interest as chairman of University College London Partners, and join others in welcoming the Minister to his new responsibilities. With regard to the current performance in accident and emergency departments, part of the explanation in the past has been the lack of access to and availability of primary care services. What thought have Her Majesty’s Government given to the potential for the provision of GP primary care services within accident and emergency departments? How is that work going forward and how might it be integrated with the broader provision of primary care services in the community?

[Lord O'Shaughnessy]

I thank the noble Lord for that question; he speaks with a great deal of knowledge and wisdom on the subject. Clearly, to ensure that we have the best possible services, the system needs to be as flexible as possible to local requirements. As is already happening in some areas, having GPs in A&Es as part of the triage, the streaming service, will provide that kind of efficiency and effectiveness, so that everyone is treated properly. I do not have the detail on where NHS England is on that process, but I will be happy to write to the noble Lord with more detail.

Medical Students

Lord Kakkar Excerpts

Wednesday 26th October 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, predicting the future requirement for doctors is extremely difficult. It is more a matter of prophesy than science. The fact that we are now going to fund an extra 1,500 doctor places a year, which is a 25% increase, should make a huge difference.

[Lord Kakkar (CB)]

My Lords, I declare my interest as chairman of University College London Partners. Beyond undergraduate medical education, do the Government believe that there are sufficient opportunities for the established workforce to continue to develop itself to meet the changing needs of the population of our country?

[Lord Prior of Brampton]

That is a very big question, which is hard to answer. My personal view is that I do not think that the training we give to our young doctors in management, leadership and how to structure new models of care is sufficiently broad. You could argue that the curriculum at medical school is too narrow and should be broadened.

NHS: Health and Social Care Act 2012

Lord Kakkar Excerpts

Thursday 8th September 2016 Lords Chamber

[Lord Kakkar (CB)]

My Lords, I join in thanking the noble Viscount, Lord Hanworth, for having secured this important debate and in so doing declare my own interests as chairman of University College London Partners, professor of surgery at University College London and a member of your Lordships’ House ad hoc Select Committee for this Session on NHS sustainability.

We have heard that the Health and Social Care Act 2012 introduced new structures and new organisations to assist in both the commissioning and the delivery of healthcare, but it also put on the Secretary of State for Health, for the first time, new duties with regard to research, education and training in the National Health Service. The research function is vitally important because it is with research and innovation that we are able to develop the novel therapies and technologies that will over time transform healthcare. The duty of the Secretary of State to ensure that this is promoted throughout the restructured National Health Service—ensuring that hospital trusts, primary care and all the other arm’s-length bodies were sensitive to this requirement—is vital. The adoption of innovation will provide the opportunities as we move forward for more precision medicine and, as a result of that, to ensure that personalised medicine will transform the prospects for our fellow citizens and hopefully drive improved clinical outcomes delivered more effectively and efficiently throughout the entire NHS.

Can the Minister say what assessment has been made, since the passage of the Act, with regard to this duty of the Secretary of State? Has the NHS as a whole become more effective and efficient at delivering the research agenda? Has the performance of organisations within the NHS with regard to clinical research improved? As a result of increased research activity, have we seen greater adoption of innovation throughout the system? Are we able to demonstrate that the adoption of innovation at scale and pace, through a variety of health economies, is providing clinical outcomes for patients availing themselves of NHS facilities?

Beyond the question of research, there is the question of education and training, and once again new arm’s-length bodies, by way of Health Education England, were established as part of the Act. There was also a duty placed on the Secretary of State for Health to ensure that education was promoted and that we developed a workforce fit for purpose, recognising over time that the changing demographics of the national population availing themselves of NHS services and the change in the nature of disease that the NHS would have to deal with, with more chronic disease, would require a much more flexible workforce. We need the ability for those committing themselves to a professional career as healthcare professionals to be provided with the opportunities not only to establish themselves at the beginning of their careers but also to adapt and change over time to ensure that they can address the changing needs of our fellow citizens and the NHS itself.

How successful has Health Education England been in achieving those objectives? These were important new obligations and duties on the Secretary of State that provided excellent opportunities to transform the workforce to ensure that it was better able to deliver the changing needs of the NHS.

As part of the discussion during the passage of the Bill, there was much emphasis on ensuring early post-legislative scrutiny of the legislation to ensure that these important objectives were established. I know that in 2014 the Department of Health did undertake some post-legislative scrutiny. The outcome of that demonstrated that the principal provisions of the Act had indeed been established, but beyond that what has been achieved by way of the anticipated outcomes in those two important areas?

We have also heard in this important debate about integrated care and how so much of the purpose of the original Act was to ensure that integrated care could be delivered. This is a vital objective. The fact we will see the need to manage so much more chronic disease over time in the National Health Service demands a different approach to the delivery of care, focused no longer on the boundaries of individual institutions but on understanding the pathways that the large numbers of patients with chronic disease will have to follow—pathways that will require interaction with the hospital sector and with highly specialist centres at some times during their disease’s natural history but predominantly in the community.

One of the concerns raised during the Bill’s passage through your Lordships’ House was whether the bodies charged with regulation of the healthcare system were in a position to determine the quality outcomes achieved through true integrated care, rather than care delivered in institutions. I ask the Minister what assessment the Department of Health has made of the ability of the Care Quality Commission and NHS Improvement to assess outcomes of integrated care packages delivered across hospital and community boundaries, and their performance in terms of their clinical effectiveness and their value to the health economy across those institutional boundaries. As we move to greater integrated care, it is vital that we understand that the systems we currently have in place are adapting themselves to ensure they can assess how quality and efficiency are delivered beyond institutions and in such a way that the investment of valuable healthcare resources in new models of care always delivers the very best for our patients.

We have also heard in this important debate about the vital need to explore further the link between healthcare and social care. Sir Cyril Chantler, a distinguished clinician, in a letter to the Daily Telegraph last month reflected on the fact that in the United Kingdom—in England—it is easy to get into hospital and very difficult to get out. One of the best-performing countries for healthcare in Europe is the Netherlands, where it is very difficult to get into hospital because there is such an emphasis on well-integrated care in the community prior to the hospital stage that they save a huge amount of resource by keeping patients in the community.

In assessing the impact of the Health and Social Care Act and the opportunities avoided by it, what has been demonstrated to date is the need to improve the collective and integrated nature of care in the community prior to hospital admission to ensure that patients might be best managed in the community, rather than admitted to institutions.

Health: Hepatitis C

Lord Kakkar Excerpts

Thursday 28th April 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, this new drug for hepatitis C is made available on the basis of clinical need, not the route of infection. There is a consultation going on about whether a special fund might be established for those who have received infected blood. I cannot answer specifically on the issue of the Welsh people but I will write to the noble Baroness on that matter.

[Lord Kakkar (CB)]

My Lords, I declare an interest as chairman of UCLPartners and Business Ambassador for Healthcare and Life Sciences. What progress has been made on the accelerated access review, which is supposed to be able to address some of these important issues with regard to the adoption of innovation into routine practice in the NHS?

[Lord Prior of Brampton]

The noble Lord makes a very good point. Of course, we hope that the accelerated access review will lower the cost of some of these drugs by shortening the time it takes to approve new drugs. We hope that the accelerated access review will report within a couple of months.

NHS: 111 Service

Lord Kakkar Excerpts

Monday 21st March 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, the decision to stop NHS Direct was, of course, taken in 2008, when I think the noble Lord was in post. He shakes his head, so perhaps he was not, but the decision was taken in 2008, before this Government were in charge, if you like. The new system uses the NHS Pathways algorithms developed by the Royal College of GPs, on which the BMA and the Royal College of Paediatrics and Child Health sit, so we have considerable confidence in the algorithms used. We will also increase the number of clinicians. I accept the noble Lord’s point that we need to have more clinicians answering these calls rather than call handlers, as he puts it. It is our intention progressively to increase the number of clinicians in these 111 hubs.

[Lord Kakkar (CB)]

My Lords, I declare my interest as chairman of University College London Partners. What assessment did the Government make of the training needs of the individuals who were to deliver the 111 service prior to its introduction, and what determination have the Government made subsequently of the appropriateness of that training?

[Lord Prior of Brampton]

My Lords, as I said, the decision to set up 111 was made back in 2008. The operation of 111, which includes the training and the capabilities of the people working in it, is carefully monitored by the CCGs—which commission 111 services by the licence under which 111 operates the NHS Pathways algorithms—and, of course, by the CQC.