Health

Lord Mawson Excerpts

Thursday 26th November 2015 Lords Chamber

[Lord Mawson (CB)]

My Lords, our health is too important a matter to be left simply in the hands of doctors and health professionals; it belongs to all of us. We must all own our well-being. It no longer sits in a convenient government silo marked “Health Service”—by the way, it never has—but what does a health-creating society look like in practice; how do you turn these aspirations into practical realities on the ground, up and down this country; and how does the health service move on from its outdated silo approaches to health and make these aspirations real in local communities? Three words are used again and again in the Health and Social Care Act as the key hallmarks of a modern health service: innovation, integration and enterprise. But how do we make them real and why are there so few examples in the health service?

I have spoken frequently, in this House and elsewhere, about the 30 years I have spent in east London, establishing an entrepreneurial ecosystem built around the Bromley by Bow Centre, which today offers a fully integrated health centre, including traditional health services, yes, but also offering a wide range of employment and housing services, the opportunity to set up your own business and a wide range of artistic and creative projects, all at one point of entry. The centre today operates on 25 sites across Tower Hamlets and offers services to 36,000 patients across a network of four integrated health centres. We have also taken this experience and a built a street in St Paul’s Way in Tower Hamlets, bringing together a wide range of services and organisations, the details of which can be seen on my website and read about in Hansard—there is not really time to describe in detail what this has been about. There is a helpful Radio 4 feature on the website and the Minister may be interested to listen to it.

I should like to share, in the brief time I have, some of the lessons we have learnt over 30 years. Over the years, one of the most challenging and regular questions we have to answer at the Bromley by Bow Centre is how our model can be replicated. Put simply, trying to replicate something as complex and contextualised as the Bromley by Bow Centre is not possible. The reality is that the centre is a response to a series of deep-seated and complicated social conditions and has evolved over a long period, not by following a clearly established recipe but by trial and error and a great deal of experimentation. However, that process of experimentation has not, in itself, led us to the “right answer”, which can then be pinged out across the whole system so that something magical will happen.

On the contrary, one of the reasons for our success is the very process of experimentation itself and a whole range of diverse people co-creating a new way of doing things over an extended period. So it is in the design process that we have created the unique model that is Bromley by Bow and, of course, this has now also happened in St Paul’s Way in Tower Hamlets. Our work is now beginning to infect the developments on the Olympic Park. A better way to frame the question is in terms of translation, rather than replication. This is a much better question and leads to a much richer answer, which is significantly different in substance and content, not just in tone. There is a basic principle behind the Bromley by Bow Centre’s model, which is that you start small and grow things.

It is a basic business model. Yet in public and statutory systems, often driven by politicians, the desire is to start big. Politicians like big programmes. They like building 200 city academies across the country or more than 300 healthy living centres, which have, by the way, not withstood the test of time. Our belief is that inventing something small and growing it in context might be far more effective in the long term; it might deliver much more bespoke and locally relevant services and be far more cost-effective long term. Our thinking is not to start with the totality of the Bromley by Bow operation—its structures, systems, budgets and business plans—but to start with the small, subtle stuff that sometimes lies under the surface.

When you spend time with us, you very quickly begin to see that the most powerful influencers of our model are very simple human principles. We are talking about a range of features that are often overlooked when new services are being designed or are put into a neat box to one side and treated like they are the icing on the cake, when in fact they are the cake.

What kind of things am I talking about? Here are my top 10 to start with. The first is the quality of the human relationships and how people interact with each other. The internet is a very important tool, but it will never replace human relationships. The second is compassion, an inbuilt sense of caring between people. There is a close correlation here with the sense that we are here to serve. The third is generosity, the idea that giving freely to people creates a sense of self-worth for both the giver and the receiver. The fourth is mutual need, recognising that none of us is fully well and that we can share our humanity together and not be compromised as professionals. The fifth is positive design and environments creating spaces that engage and provide a sense of welcome or safety, like being at home. The sixth is blurring the boundaries, as services work best when they are not in silos. We all live complex and sometimes chaotic lives, so neat solutions do not always work. The seventh is long journeys, as we are committed to generational change. So many health services seem to be obsessed with moving people on or getting them out of the door, but we believe in sticking with people. The eighth is building in fun, which is often seen as having nothing to do with work. That is a very big mistake as it is essential for success. The ninth is having big expectations. The model is all about raising aspirations and encouraging everyone, staff and clients alike, to assume it is possible. The final thing is to let go, encourage freedom to innovate and provide resources for people to be entrepreneurial.

These key features of the Bromley by Bow Centre model absolutely lend themselves to translation; we have translated them elsewhere. Every health service organisation could grapple with these features and find ways of translating them into practical changes in their own contexts. It would not lead to replications of the Bromley by Bow Centre model, but it would lead to services being transformed by shifts in culture and values. Of course, none of this is really about money or resourcing; most of it is about attitude and behaviour. Will the Minister tell the House what priority the Government give to the principles I have set out for a health creating society and what in practice they are doing to encourage this cultural change? The Minister might like to visit the street the noble Lord, Lord Crisp, and I have mentioned and see these human principles in action for himself.

National Health Service

Lord Mawson Excerpts

Thursday 8th January 2015 Lords Chamber

[Lord Mawson (CB)]

My Lords, I thank the House for allowing me to speak briefly in the gap. In the debate led by the noble Lord, Lord Kakkar, in November, on health and innovation, I described a piece of health innovation that I am leading in Tower Hamlets, bringing a health centre, a school, housing and a whole range of enterprise projects together in an integrated health and education project. Professor Brian Cox and I are embedding a science summer school in this project, focused on how Britain becomes the best place in the world to do science. It has taken us seven years to create the health centre; we have lived through three different Governments. I have to thank the noble Earl, Lord Howe, for helping us to resolve this issue; it is very good news indeed.

What lessons have we learnt from a real project on the ground over the past seven years? My first point is that we need consistency. The message and the people constantly change. Secondly, there needs to be accountability. No one seems able to take a decision; there are layers and layers of approval processes, requiring business case after business case, then point one comes in—I refer to my point about consistency—and you are back to square one.

Thirdly, we need clarity. To the outside world, the NHS is the NHS is the NHS. Unfortunately, within the NHS there are so many silos that only the NHS can understand and which all have to have their say, and they all have different approval mechanisms. Then, because of the accountability processes, nobody can take a decision, so it becomes a game of “We will agree if they will agree”, with no one willing to make a final call.

Fourthly, there must be local empowerment. The centre has to make all the decisions but it is the people on the ground at a local level who should be leading. Locally, things are either done to you from the centre or not done at all.

Fifthly, there needs to be partnership and trust. We are not all the evil private sector, all out to screw the NHS. Partnership can achieve so much and has done so to date. The NHS has got to learn to trust and work with others, and it may just find that it can benefit enormously. The best local authorities have made real progress here, but the NHS by and large has not. Our project is bringing large amounts of money, which are coming from outside the NHS budget, into health initiatives on a housing estate. That is what partnership does.

Sixthly, on primary care premises development, the Secretary of State is continually talking about moving to a more preventive and proactive approach, and he is right to do so. To do this, you need to do all that I have mentioned above. However, NHS estates have been given a very narrow, financially driven brief. They need fresh instruction and leadership with a specific brief to foster partnership and opportunities for GP practice developments that will then deliver a preventive and cost-effective, proactive approach. They need to be the solution, not the problem—because not despite.

Most importantly, it must be about patients, patients, patients. Some parts of the NHS seem to have forgotten all about that.

NHS: Health Improvements

Lord Mawson Excerpts

Wednesday 26th November 2014 Grand Committee

[Lord Mawson (CB)]

My Lords, I thank the noble Lord, Lord Kakkar, for introducing this important debate. I will focus my remarks on innovation in the primary care setting.

The report Creating Change: Innovation, Health and Wealth One Year On, published in December 2012, makes two references to community. The first was the procurement community and the second was the research community, and therein, I suggest, is the fundamental problem.

If you look at how primary care is being run in developing countries, you will find a clue to what works and what is cost-effective. They do not send in professional teams at great expense to change the behaviour of patients. They invest in informal networks, particularly among women, because that is how you get the key programmes running at the front edge. In this country we seem determined to professionalise everything. Instead of creating relationships, networks and local gossip, we churn out papers and reports.

I have made these opening remarks because my conversations with the senior consultant at Barts and the London, who is responsible for working on our national diabetes crisis, tells me that his department is already overwhelmed by the scale of the health problem and that the only real solution to it lies in the community.

An impending epidemic of diabetes faces this country. It has already arrived in east London. It is not because people are ill but because they have unhealthy lifestyles. To address this challenge we genuinely need everyone working together in the local community: the school, the health centre, the pharmacy, businesses, the voluntary sector and local parents. This is where innovation is needed, yet we turn to the procurement community and research community. The message for patients is, “Health is not something I own; it is something that professionals do to me”.

At the moment there are lots of projects that try to join up service delivery and connect with the community, but the delivery of actual programmes affected does not change very much because often the professionals say that they cannot afford the overhead of the meetings needed to discuss the programmes, so people revert to type. Thus innovation and change become stifled. We need people collaborating on practical projects—“learning by doing”—but doing things in a significantly different way.

Let me share a practical example of what I mean. I declare an interest as the director of the St Paul’s Way Transformation Project. Seven years ago I was asked to intervene in a group of deprived housing estates in Tower Hamlets by the then CEO of Tower Hamlets council, Christine Gilbert, and the CEO of the local health service. A young man had been murdered and another set on fire, and there was serious concern across the public sector and beyond. Despite the many years of successive Governments talking about joined-up thinking and the need for integration, I found a failing secondary school with 1,000 pupils, the GP practice next door injecting 11,000 patients with dead vaccines stored in a cheap domestic fridge, and the excellent pharmacist across the road, a respected member of the community, being ignored by public bodies. Everybody was operating in silos and basic human relationships between the key leaders in health and education were not in place. No one was investing in any joined-up thinking, let alone action, and little innovation was taking place.

Six years later, by bringing the key leaders together and building relationships between them, we have a rather different situation. The new, recently opened £40 million school, to which only 35 families applied five years ago and which was one of the bottom 10 schools in the country, had 1,200 families apply this year. Six months ago Ofsted rated the school outstanding in every regard. Across the road from the school, the local social housing company has built a new £16 million health centre, with the agreement of the then PCT, in a campus development. The plan is that this will open shortly with a team of new GPs, working alongside a diabetes DNA research laboratory run by the school and Queen Mary University of London. The students at the school will be researching the causes of diabetes in the 11,000 patients, many of whom are extended family members.

The first phase of 500 new mixed-tenure homes has been built, alongside a new community services centre. Support from JPMorgan Chase, just a few hundred metres to the south, is now enabling pupils at the school to start their own businesses. Our patron Professor Brian Cox and I have just run a very successful third science summer school, addressing the issue, “You are what you eat”. This year the science summer school brought together 30 schools in east London.

How did we do it in six years? At its core, it was about establishing relationships between the key leaders responsible for the local health service, education and housing and getting them to communicate with resident leaders and to be entrepreneurial. The result is a piece of innovation that is now generating further innovations in health, education and housing. We are all learning by doing things together. This is where innovation and integration start. None of these individual activities alone will solve the diabetes crisis in east London but, by combining our shared efforts and resources over a period of time, we will change behaviour patterns and patients will start to see themselves as responsible for their own health.

Innovative, integrated programmes like this are the exception rather than the rule. Why is this? Negotiations on securing the integrated health centre that I mentioned have dragged on for seven years, through one NHS structure after another. Jeremy Hunt helpfully assured me in the summer that we were nearly there, yet minutes before I came into this Committee I was unexpectedly phoned by the chairman of the housing company that is bearing all of the costs and was told that she, a very experienced businesswoman, had had enough—today, yet again, another group of civil servants asked to renegotiate the lease.

Bernadette Conroy is a former colleague of the noble Lord, Lord Green, and a senior person who used to work at HSBC. She has now given the NHS 24 hours to come up with a decision rather than prevarication, or she will walk away and this opportunity at the frontier of health innovation will fall. I ask if the Minister can help. We have been on the case for seven years and we are all becoming exasperated.

Innovation in the health service is a very challenging business. When you are operating at a new frontier, you need friends and leadership that grasps the opportunity when it arrives. The opportunity for innovation in health has now arrived at St Paul’s Way in Tower Hamlets. I ask for a helping hand from the NHS.

Elderly People: Abuse

Lord Mawson Excerpts

Wednesday 14th May 2014 Lords Chamber

[Lord Mawson (CB)]

My Lords, I, too, thank the noble Baroness, Lady Cumberlege, for introducing this debate. Three months ago, my 95 year-old mother, living alone, had a heart attack early one morning at home in Bradford. The ambulance was called and the paramedic saved her life by deciding to take her by blue light the 15 miles to a hospital in Leeds because he feared the local hospital in Bradford, serving half a million people, was not up to the job. That paramedic’s good judgment saved her life and now she is back home and, amazingly, recovering well.

My mother has fortunately lived a well and independent life and so has not often had to use the health and social care system, so this was all quite new and a fresh experience for her as she became catapulted into the NHS institution. As a person who was now totally dependent on others, at this point she felt that she had a good experience of the system and was treated well by many of the NHS staff. Those of us in the family, however, less dependent and observing the system close up, were left with a few questions to ask. Abuse of the elderly can be subtle, and large, well-meaning government-facing institutions with a tick-box culture can be very inhumane and impersonal, with the best will in the world.

First, on visiting my mother in hospital after the incident, I was greeted by more than 71 notices either side of the door of the ward telling me what to do as well as to wash my hands. If we are the environments we live in, then McDonald’s has a more welcoming environment and clear communication with the customer than this. It is all very amateur and confusing for visitors and patient alike.

Secondly, why did the initial meeting with the social worker not include a person from the health service? It was held in the hospital. Why was a plan that was agreed to by the family then totally ignored and not taken forward when my mother reached the community hospital nearer home? The health people down the line knew nothing about it. Personal communication is essential if vulnerable elderly people are to feel secure. Why are these basics still so difficult in the age of the internet?

Thirdly, why were staff in the local cottage hospital telling us confidently that they did not normally speak with social services—“Nothing to do with us, love”? Why was there no evidence to us that health and social care were partners? At one point, when they did meet, they had an argument in front of the patient. If it is all about working in partnership at a basic level, they still did not seem to get it. My family’s experience of the system was that, despite all the rhetoric about a seamless service, in reality health and social services still seemed to work in separate universes.

Fourthly, why was my mother not given a bath at the new cottage hospital in the four-week period that she was there but had just hand-washing? Is this not rather basic care for a 95 year-old? She wanted a bath. Why when she came home did the social worker then tell my brother, a retired experienced nurse, that he could not arrange a bath at home either until she was given a “bath assessment” at the end of May, weeks later? And we are still waiting. Why did he tell us that the policy was that he could help my mother out of a bath at home but not help her into it? It was health and safety, we were told. Members of the family did the business, but it is all very confusing for sane people.

Finally, why when an assessor comes around to visit my mother at home is this professional not allowed to use her common sense and good judgment? My mother told me she arrived with a pen and piece of paper in her hand, and asked my mother if she knew how to make a cup of tea. “Sit down, love”, my mother said. “I’ve been making tea for 90 years. If I haven’t mastered it by now, there is something seriously wrong”. Treating elderly people like children for the sake of a form that keeps civil servants happy up the tree is abusive, makes the elderly people cross and, by the way, often tells us little about the reality on the ground. My questions to the Minister are: when will these systems receive some innovation and when will we learn—as the noble Lord, Lord Griffiths, rightly said—what caring communities are all about?

NHS Property Services Ltd

Lord Mawson Excerpts

Thursday 30th January 2014 Lords Chamber

[Earl Howe]

My Lords, on administration costs, the company is already reviewing the way in which its strategic asset management and facilities management functions are structured. It is probably inevitable that the consolidation of 161 PCT and strategic health authority estates into one will throw up duplication, overlap and operational policies that conflict. These all need to be rationalised and a commercial ethos introduced. It is vital that the skills are imported into the organisation to match that challenge.

[Lord Mawson (CB)]

My Lords, for the past six years, we in St Paul’s Way in Tower Hamlets have been pursuing the Government’s policy of integration in health services, bringing together a school, housing, health and community services centre on one street. I was asked to lead this project following a murder and considerable racial violence on this housing estate. The overall transformation project has been very successful, and I must declare an interest. However, the primary care premises elements have stalled and we are going backwards in terms of dental outreach facility. Can the Minister explain how NHS England engages with NHS Property Services, the CCG, local GPs and local partners to deliver in an effective and timely manner the kind of innovative and integrated premises we all agree are essential?

[Earl Howe]

My Lords, I pay tribute to the work that the noble Lord does. However, it is important to understand that the decision as to whether a property in the NHS Property Services portfolio is surplus to requirements and should therefore be sold resides with the commissioners; that is, NHS England and clinical commissioning groups. It is up to the commissioners how they wish to utilise the estate.

Health and Social Care Bill

Lord Mawson Excerpts

Monday 27th February 2012 Lords Chamber

Moved by

[Lord Mawson]

64A: Clause 22, page 20, line 24, at end insert—
“13OA Duty to have regard to the voluntary and social enterprise sector
(1) In exercising its functions, the Board must, so far as it is consistent with the interests of the health service, act with a view to ensuring that competition does not disadvantage the voluntary and social enterprise sectors.
(2) The Board may take specific action to support the development, including capacity building, of the voluntary sector, social enterprises, co-operatives and mutuals as it considers appropriate.
(3) Any action the Board takes in subsection (2) shall only be such that a level playing field between providers is achieved and maintained, meaning that one sector of provision is not more disadvantaged than another and the relative benefits of each form of organisation can be taken into account.”

[Lord Mawson]

My Lords, I shall also speak to Amendment 64B. Many fine words have been spoken by this and the previous Government about the important role that social enterprise and the voluntary sectors now need to play in our changing economy, particularly in the NHS. Indeed, on 25 January, the Prime Minister spoke to exactly this subject in the other place, and in 2010 Secretary of State Andrew Lansley said during a speech to the voluntary sector leaders that he was assisting in the creation of the,

“largest social enterprise sector in the world”.

Indeed, he said that it would mean opportunities for this sector,

“at every stage in the process”.

These are very fine words, with which I agree. These two amendments are intended to turn these aspirations into practice on the ground up and down this country, because it is simply not happening when one looks under the carpet and at the fine detail. Whatever we think the numbers produced by civil servants tell us, something quite different is happening on the ground in practice.

When this matter raised its head in Committee, I reminded your Lordships’ House of our practical experience in Tower Hamlets, where the social enterprise the Bromley by Bow Centre—I declare an interest as its founder and president—had competed with a large multinational company to run a local health centre. Having invested many tens of thousands of pounds in the process, the centre lost the bid on cost.

Fair enough, one might say: that is life. Because I was conflicted at the time, I kept out of the process but, as soon as it had finished, I realised that a very large company had undercut the centre and come in at a price that was simply not sustainable for either it or the patients, and that the inexperienced procurement officers in the PCT had no idea about what they were dealing with in practice—they had never run a health centre. Lo and behold, very quickly the company was adding new variation orders to the contract to up its value, and by year 3 asking to be relieved of its responsibilities under the contract.

The centre now runs the service, having wasted a great deal of money as a charity in the application process. The company was good to deal with, but the process was hopeless. One can imagine the messiness this contractual process created in a local housing estate which had had poor health provision for years, because in practice the local GPs were not held accountable. This was not good for patients and it was certainly not good for business.

--- Later in debate ---

[Earl Howe]

My Lords, as regards grants and loans, we are clear that voluntary sector organisations and social enterprises—and I include bodies of that kind in the same grouping—are and will still be eligible for grants. The key is that those grants must not be given solely because they are voluntary sector organisations or social enterprises. It is a nice distinction, but really it means that voluntary sector organisations and social enterprises will still have to compete fairly for a contract on a fair playing field with other providers. As I have indicated, that means that NHS providers and others are not disadvantaged in the market for NHS-funded services. Nevertheless, the scope will still be there, and they are indeed classed as voluntary sector.

I am also grateful to the noble Lord for raising the important issue of social value. I can assure him that the Government are sympathetic to these principles. That is why the NHS procurement guide already enables NHS commissioners to take account of social and environmental outcomes in their procurement. The Department of Health has also, through its social enterprise fund, invested more than £80 million in the health and social care sector. To answer my noble friend Lord Newby, I am also fully aware of the support for these principles in the Public Services (Social Value) Bill currently being considered by noble Lords. Put simply, if that Bill receives Royal Assent, Amendment 64B will not be necessary. The Public Services (Social Value) Bill will make NHS organisations have regard to economic, social and environmental well-being in procurement, and the Government welcome that. The NHS procurement guide, as I said, already enables NHS commissioners to take into account other outcomes in procurement, and we will continue to encourage them to do that, so I think, in the NHS at least, commissioners will notice little change in the guidance that is given to them. Make no mistake, we see a valuable role in the future healthcare system for voluntary sector organisations, social enterprises, staff mutuals and co-operatives. However, that cannot be at the expense of other types of provider, including particularly NHS providers. I hope very much that your Lordships will agree that these two amendments are therefore unnecessary.

[Lord Mawson]

My Lords, I am most grateful to the Minister for what he has had to say. I am trying not to be difficult but to be practical. The future of the health service depends on practical details being got right in the machinery of the NHS, which is where I seek to draw the Minister’s attention. For me it is not about words about whether it is the health service, or patients, or words in an amendment; it is about what is actually going on in the machinery. I fear that the practice is still too little understood and that there is more work to be done here. I know that this is the beginning of a journey and that we have further to go with the various elements of the jigsaw.

The purpose of the amendments was really to draw the attention of the Minister and the Government to this and to encourage them to focus on the detail, and to encourage colleagues within the NHS to spend a bit of time with practical entrepreneurs who have to try to make this work. We want them to examine in a few details some real pieces of work where people have attempted through weightings and other mechanisms a level playing field—because people like me do not want special favours, but we do want a level playing field. All that I can say is that in practice it is not level. The Government aspire to a broader involvement in the health service with social enterprise and others in the voluntary sector but, unless those practical details are better understood and addressed, I fear something quite different will happen.

Having said that, I thank all those who have taken part in this debate and who helped me with the amendments—particularly the noble Lord, Lord Rooker, who is not in his place, but who has been very helpful. The noble Baroness, Lady Tyler, has also been very helpful. This is not a party-political debate; it is a practical matter that seeks to help to move the NHS on into new, more patient-focused reality. The amendments are simply an attempt to flag up yet again the issues. I beg leave to withdraw the amendment.

Amendment 64A withdrawn.

Health and Social Care Bill

Lord Mawson Excerpts

Wednesday 21st December 2011 Lords Chamber

[Earl Howe]

My Lords, first of all, the Bill does not provide for PCT property to be transferred to GP practices. The policy on where property may be transferred is still under development but we have powers in the Bill to transfer property to the appropriate body in the new architecture. The noble Baroness will realise that many decisions around this have to be taken locally on a case-by-case basis. We have powers in the Bill to create schemes with enough flexibility to allow this.

If, for the sake of argument, a clinical commissioning group owns property which is surplus to requirements, it will have to go through all the proper processes overseen by its own audit committee and its governing body to ensure that public assets are disposed of for value and in a proper and arm’s-length way. Where a conflict of interest rears its head, the provisions governing conflicts of interest will cut in. It will not be open to the clinicians who have authority within the clinical commissioning group, or, indeed, practices which are members of the clinical commissioning group, to benefit in an improper way. It will have to be done openly. If a GP practice were to wish to acquire property that is owned by the CCG, there will be transparent processes to make sure that this is done in the correct fashion. In these circumstances, the property deeds are transferred to the clinical commissioning group as a corporate entity. They are not transferred to the individual GP members, and once transferred to CCGs, if the governing body wished to dispose of property, that, as I say, has to be done in accordance with the same safeguards that currently apply to PCTs. I hope that that reassures the noble Baroness.

[Lord Mawson]

I encourage the Minister to look very carefully at the practicalities of this because I can think of at least two or three examples of health centres in which I have been involved where it did come down to the property, the ownership and the GP—I can think of one now—where one brought together all the practitioners and key community groups to secure development. The person who stopped that development was the GP because of their interests and pension arrangements in the building. Therefore, in my view, it is important to be very careful about these practical arrangements if we want integration to occur.

[Earl Howe]

I suspect that the example the noble Lord has in mind involved GP practice premises rather than property owned by an NHS body such as a primary care trust. I suggest that the two cases are rather different. However, I take the noble Lord’s point that integration of services at a delivery level can often be very advantageous to patient communities. Some of the most successful examples that I have seen are of practices where many facilities are available on site for the patient. We are seeing more and more of these being created around the country. We should encourage that.

Health and Social Care Bill

Lord Mawson Excerpts

Monday 28th November 2011 Lords Chamber

[Baroness Jolly]

My Lords, I can give an example of where it has been provided. Today I have been talking to the operations director of Peninsula Health Care. That was the provider arm for the Cornwall PCT which was providing community hospitals and community services, and which is now a community interest company as of 1 October 2011. It has already brought across all the arrangements that it has with its local authority; Section 75 and so on, shared budgets for equipment, and all sorts of innovative work alongside.

The whole thrust of the amendment of the noble Lord, Lord Rooker, was part of our manifesto, it was part of the coalition agreement, and I feel quite comfortable about supporting it.

[Lord Mawson]

My Lords, I am very sympathetic to the amendment of the noble Lord, Lord Rooker, for very practical reasons. I am building a street at the moment in Tower Hamlets, and part of that street is not only a new school but a new health centre, which has been under development for five years. The health centre proposals were begun in the previous Government’s time in office. It is true that the Bromley-by-Bow Centre, when competing for that practice, was not on a level playing field. It is very difficult to compete with a multinational company that could undercut the price per patient to £75 per head, when I, having run an integrated health centre for 20-odd years, knew that the real costs were probably around £119 per patient and that the £75 per patient was not sustainable. It was very interesting going through the whole of that process, of proper competition and then losing the competition, to three years later, when I was approached by that company which admitted that the business plan did not work and asked whether we could help rescue the situation, which we have now done, and the multinational business has now withdrawn. I know that there is a problem here that we need to get our heads round, and I know and believe that the Government are serious about wanting the social enterprise sector and the voluntary sector to play their full role. It is a practical problem that needs to be got hold of.

The other thing that I know from experience is that bureaucracies like to talk to bureaucracies. I know that large government departments often find it easier to talk to large businesses. Indeed, we have seen this happen over many years. I am in favour of the private sector. We work a lot with the private sector, and I do not think that it is a case of one of the other. However, I have noticed how easily civil servants translate across into large companies, with the bureaucracy carrying on under other names, and organisations that are leaner and more innovative sometimes find it very difficult to break in. Therefore, if the Government are really serious about allowing some of us who do this work but are smaller in scale to break into this market and grow in capacity, then something will need to happen here to help that.

I also know from experience that one way in which we have grown in capacity is by forming relationships with one or two businesses. They have got to know what we are about and we have got to know what they are about, and we have formed partnerships and grown opportunities together. As I mentioned earlier, a £35 million LIFT company has now built 10 health centres. When we formed that relationship, which is a bit like a marriage, we got to know about each other’s worlds. We are now in a social enterprise with that business carrying out landscape work on 26 school sites. Therefore, there are things that government can do.

In my experience, some businesses are becoming more intelligent about this, although some businesses are not. The Government should be using their muscle to encourage businesses to form these local partnerships. If they do not do that, the danger will be that the profits made in poorer communities will be sucked out of the area, rather than there being virtuous circles around the areas creating more jobs and opportunities in local contexts. Therefore, I am sympathetic to the amendment. I would encourage the Government to look again at some of the practical issues and how they work in practice on the ground.

[Lord Beecham]

My Lords, for centuries what is now termed the voluntary or charitable sector was the main provider of health services in this country. It is a common view across your Lordships’ House that the sector must be encouraged to play a growing part in the provision of services, partly because it has a track record of innovation, is less inhibited by cumbersome regulations, and perhaps, as I have said on a previous occasion, is a little less risk averse than public bodies tend to be and obviously less motivated by the profit motive than the private sector necessarily has to be.

Surely it is common ground that we want to see a thriving voluntary sector, and I credit the Minister with sharing that aspiration. The trouble is that the Bill does not help him to do that. At best, this clause is neutral in its attitude towards the voluntary sector and, at worst, it will conceivably endanger the realisation of that aspiration. The noble Lord, Lord Greaves, pointed to the curious phrase in paragraph (b), seeking some elucidation, which we may get. However, as it stands, that paragraph could easily be interpreted as referring to the charitable and voluntary sector and as placing that sector at a disadvantage because it would be brought within the scope of the provisions of the clause, which would prevent any positive discrimination—if I might put it in such terms—in favour of that sector. That may not be the intention but it would appear to be very likely to be deemed to be the outcome.

There are already significant inhibitions, as a number of your Lordships have pointed out. The noble Lord, Lord Rooker, referred to the central Surrey experience, where a £9 million performance bond was requested from a social enterprise which clearly was not able to provide it. Incidentally, I contrast that with the financial position of Circle, which had a £45 million pre-tax loss in the year prior to the award of a contract to it and apparently very little relevant experience in running a hospital facility. However, it was awarded a contract. It would be interesting to see what criteria would be applied in future cases of that kind, whether to social enterprises, enterprises purporting to be social enterprises, such as Circle, or other enterprises. Be that as it may, there are clearly considerable difficulties for the social enterprise sector. Social Enterprise UK in its briefing, which no doubt some of your Lordships will have had, points out that the clause could also prevent the continuation of policies such as the Social Enterprise Investment Fund, which helped to support social enterprises in their endeavours.

The noble Baroness, Lady Williams, bravely interposes herself between the raging Opposition and the beleaguered Minister—as he appears to deem himself—but for what purpose I really cannot quite understand. Nobody is doubting his bona fides; the question is whether the legislation reflects his intentions. The very best that can be said of the clause which the amendment of the noble Lord, Lord Rooker, seeks to improve is that it creates a neutral situation. However neutrality, like patriotism, is not enough in this context. If we want to support the sector then we have to recognise the disadvantages with which it starts and not go for a simple level playing field on the assumption that all parties on the field are equal. We have to prepare the ground to assist this particular sector. At the moment, I do not think that the Bill provides for that.

The amendment does not require the board to favour the sector. I might have gone along with it had it done so. It provides the option for the board to assist the sector in making its particular and distinctive contribution to the provision of health services and removes what would be a substantial obstacle to that happening. This clause reflects a positive attitude to a sector that needs that kind of support. I therefore hope that the noble Earl will accept the suggestion made by my noble friend Lady Thornton in the earlier debate and hold some kind of discussion with representative bodies such as ACEVO, which is clearly concerned. The chief executive of ACEVO was a member of the Future Forum and his views should be taken very seriously. There are other organisations, some of them already in the field providing services, which clearly have an interest in this. The hospice movement, which has been referred to, is a very good example. A meeting convened by the Minister would be very helpful in that respect.

Social enterprises are perhaps slightly different from traditional third sector organisations. They are essentially a new form of enterprise in this field and again they ought to be represented at such a discussion. At the very least, I cannot see what the Minister would have to lose by accepting the noble Lord’s amendment. It does not impose a positive requirement. It does not prevent other parties being involved in undertaking work or competing for the provision of services in this area, it merely provides for a third option. If that is consistent with the Minister’s approach I cannot see what the Government have to lose by accepting it. It certainly is no reflection on his intentions, as I am sure the noble Lord would confirm and as I have repeatedly said. I therefore hope that the Minister can respond positively—if not tonight by simply accepting the amendment, which would be the easiest and most preferred course for many of us, then at least by entering into discussion with a view to assessing the degree of difficulty that the sector fears would arise from this provision. We could then see on Report whether we might amend the clause something along the lines of—if not on the actual lines of—what the noble Lord, Lord Rooker, has proposed. That would meet the wishes of all Members of this House to see a thriving sector contributing in that mixed-economy provision to which we all subscribe.

[Lord Mawson]

My Lords, I would certainly be willing to help with this. It is one thing to talk to representative bodies: that is fine. However, the Government might find it helpful to talk to individuals who have dealt with the nitty-gritty, practical realities of the situation, and who may have practical insights that could help the Minister with some of these issues. I would be willing to suggest one or two people if that would be helpful.

[Earl Howe]

My Lords, I have had a lot of helpful comments in the debate and very much welcome the chance to reiterate the Government's support for the work of the voluntary and community sectors. The noble Lord, Lord Rooker, is absolutely right; these organisations have a very important role to play both in the provision of support to patients and their families, carers and communities, and increasingly in the provision of services. It is right that the NHS Commissioning Board and clinical commissioning groups should be able to provide funding to support them in this work. The noble Lord suggested that the effect of the Bill would be to snuff out the third sector. I assure him that that is not so.

I will quickly clarify the effect of the duties relating to market share. We want the NHS to operate around the needs of patients. That is why patients’ interests are at the heart of the Bill. Healthcare services should be commissioned on that basis and not on the basis of who is providing the care. This will not prevent a range of work that may go on to support the voluntary sector where it does not directly provide healthcare services. I believe that the Bill goes further than any previous legislation to remove barriers standing in the way of a fair playing field. I do not and will not shy away from our commitment to see a vibrant third-sector market in the NHS.

I will provide a little detail and flesh on the bones. The Bill already provides the board and clinical commissioning groups with the power to make payments through loans and grants to voluntary organisations that provide or arrange for the provision of similar services to those that the board will be responsible for commissioning. This power mirrors the power that the Secretary of State has under Section 64 of the Health Services and Public Health Act 1968, currently exercised by strategic health authorities and primary care trusts. The power would not apply only to service provision. The board and clinical commissioning groups may also want to fund work that will assist in the effective commissioning of services. For instance, the board may provide funding to voluntary organisations with particular expertise in the provision of support to people with rare specialist conditions to guide its approach to commissioning those services. Grants and loans of this sort will support innovation and vibrancy in the health sector and we want to encourage this.

I reassure the noble Lord that we expect that the NHS Commissioning Board and clinical commissioning groups will also continue to uphold the principles set out in the compact. This remains a key agreement between the state and the voluntary sector. Local commissioners should make every effort to engage their voluntary and community partners in discussion on priorities and the allocation of resources, working in a way that is transparent and accountable to local communities. I know that that is already happening at the level of pathfinder CCGs.

The noble Baroness, Lady Armstrong, chided the Government by saying that their rhetoric had not been followed through into action. I say to her that voluntary sector grant schemes are still in place. These are the innovation, excellence and service delivery fund, the strategic partner programme, opportunities for volunteering and the health and social care volunteering fund, under the collective umbrella of the Third Sector Investment Programme. The total value of this for the current year is £25 million. It will continue in 2012-13, which will ensure the continued support of its member organisations to build their capacity and capability to make high-quality and responsive contributions to support health and well-being in our communities. A £1 million financial assistance fund opened on 20 December last for organisations that make a significant contribution to health, public health and social care, but which are most at financial risk. In addition, the department contributed to the Office for Civil Society’s transition fund.

As I say, the department greatly values the voluntary sector’s contribution and our ongoing support for the grant funding programmes through this year recognises the increased role of the sector in helping us renew our efforts to build strong, resilient communities and improve health and well-being outcomes. What I cannot precisely do at the moment is say how much money will be available next year. Decisions about budgets for 2012-13 will be made in due course and we will work within the principles of the compact in making those decisions.

I hope that what I have said has served to reassure the noble Lord, Lord Rooker, that we are serious about this and indeed I hope he will accept from me that nothing in the Bill interferes with our purpose to support this important sector. Our policy is that services should be commissioned from the providers best able to meet the needs of patients and local communities. That is the key. Unfortunately, the wording of his amendment, if taken literally, would run counter to that principle, which is why I am afraid I cannot accept it, but I hope he will find some comfort in what I have said.

Health and Social Care Bill

Lord Mawson Excerpts

Monday 28th November 2011 Lords Chamber

[Baroness Cumberlege]

My Lords, I have tabled three amendments in this grouping: Amendments 110C, 131A and 190C. I am grateful to the noble Lord, Lord Patel, for supporting the amendments because they concern maternity services, and I do not think I could have anyone more distinguished than the past president of the Royal College of Obstetricians and Gynaecologists, although of course the noble Lord is also involved in many other things, not least this Bill. These are probing amendments, the first of which seeks a commitment from my noble friend the Minister that the Government, through commissioning at the national and the local level, will give women and their partners real and informed choice in maternity services. The second amendment would ensure that there is less variation in the quality of services provided, and the third concerns maternity networks, including independent midwives.

The variation in maternity services across the country is quite startling. Sometimes the poor performance is a reflection of a lack of resources or priorities, but one of the reasons for this is that maternity services have been overwhelmed by the rising number of births, including more complex cases. This is partly due to the increase in the number of older women giving birth. Last year the number of women giving birth aged over 40 was the highest since 1948, the post-war period, and we can surmise about that. In the past 10 years in England, the number of births overall has risen by 22 per cent, which means that more than 10,000 extra babies are born every month. There has been a modest increase in midwives, and we should be grateful for that, but they are being run ragged by this record-breaking baby boom.

The Bill seeks to ensure that the quality of NHS services will improve by using new and increasingly much more sophisticated commissioning systems. If this key objective is to be realised, it will require commissioning of a very high quality. Pathfinder clinical commissioning groups are beginning to get a grip and to understand the health needs of their local populations, but inevitably others will lag behind and we will see variations in commissioning. One of the ways to address this is through a NICE quality standard, as already discussed by the noble Lord, Lord Butler, and my noble friend Lord Newton. But as the noble Lord, Lord Walton, said, even when these standards are produced, advice from NICE is not always adhered to, and I understand that the queue for these quality standards to be produced is very long, with maternity services some way down the line.

On quality, proposed new Clause 13E(1) states that the NHS Commissioning Board should improve the quality of services in three areas: prevention, diagnosis and the treatment of illness. On prevention, however powerful the board is, it is going to find it a real task to prevent wanted pregnancies—even Solomon in all his glory failed to do that, and he knew quite a bit about babies. On diagnosis, I do not think there is much problem in diagnosing pregnancy, as it is usually pretty obvious to those concerned. On the treatment of illness, certainly most women who are pregnant are not ill; on the contrary, many take enormous care of themselves and are extremely fit and so will not need treatment for illness.

Looking at those three criteria in that subsection, I think that they do not fit with maternity services. Therefore, we have a lacuna, which I am trying to fill with my first amendment. I suggest that the Commissioning Board keep a watchful eye on the situation in England and use a means—possibly a specification or some other mechanism—which would act as a guide to enable commissioners to buy services from NHS trusts at a set quality, until NICE has produced its quality standards.

My second amendment concerns choice. I apologise because I think it has been positioned rather wrongly in the Bill, but it is another probing amendment.

“Pregnancy is a long and very special journey for a woman. It is a journey of dramatic physical, psychological and social change; of becoming a mother, of redefining family relationships and taking on the long-term responsibility for caring and cherishing a new-born child. Generations of women have travelled the same route, but each journey is unique”.

I wrote that in the foreword for Changing Childbirth, which was a government policy document that I produced many years ago. It is because each journey is unique that women and their partners should have as much choice as possible, because we know choice is empowering. Giving birth can be wonderful, but it is also very traumatic and the start to a new life can have long-term consequences for the baby as it enters childhood and later adult life.

New Clause 13I, places a duty on the board to enable patients to make choices in the services they receive. Pregnant women and their partners have four main choices when considering where to give birth: at home, in a free-standing midwifery unit, in a midwife-led unit situated alongside a hospital or in a hospital led by a team of obstetricians. This is the theory, but it does not actually work in practice. Delivered with Care, a national survey of women’s experiences of maternity care in 2010, undertaken by two very respected researchers in the field, found:

“Many women (80 %) were not aware of the four possible options for … birth”.

Therefore, how can potential parents choose when they are not even aware of the options? Why do health workers, especially GPs, seeing a woman at the first booking, not tell them what is available? The majority only tell them where to go, and that is hospital.

In a joint statement the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives, in their introduction to a paper on home births state:

“The rate of home births within the UK remains low at approximately 2%, but it is believed that if women had true choice the rate would be around 8-10%”.

It is part of government policy to give choice, including birth at home, to every pregnant woman. In Somerset 11.4 per cent of births are at home, whereas in Wansbeck the figure is just 0.1 per cent. Of course there may be a range of factors affecting this—I suspect housing and other conditions also play a part—but this discrepancy is so great that I am sure it is partly due to the fact that mothers were not even told what was available. I would like to ask the Minister how he sees the NHS Commissioning Board addressing its duty in new Clause 13I as to patient choice in maternity services. I appreciate this is quite a minority sport so the Minister may like to write to me on this issue.

My third amendment concerns maternity networks. Neonatal and cancer networks, where they work well, have proved to be highly effective. It is a model that those in maternity services wish to adopt. They believe that effective, inclusive and supported maternity networks have the potential to ensure that all women, within the network locality, are able to access the full range of services from pre-conception to early years. The networks would be able to promote choice within these services and work with all providers to ensure that women are offered and are able to exercise informed choice. The existing networks have received funding for their infrastructure, which has enabled them to be effective. Will my noble friend consider a similar commitment from the Government to support the development and sustainability of maternity provider networks and ensure that they are properly resourced?

Part of the network should be the care offered by independent midwives, who give a highly specialised and personalised service, accompanying the family through this wonderful but often stressful time in their lives. There are around 130 independent midwives in the country, but there are about 800 who would choose to work in this way if they could get professional indemnity insurance. Currently that is not the case because of market failure to provide for it.

The EU Council of Ministers has issued a directive on patients’ rights on cross-border healthcare that requires member states to ensure that systems of professional liability insurance are in place for treatment provided on their territory. The Government ratified this directive on 28 February this year, which means that all midwives in independent practice in the UK will need to be able to access this insurance from September 2013 in order to be registered with their regulatory body, the NMC. Without registration, they will not be able to practise midwifery legally; independent midwifery will disappear, unless a solution to the insurance conundrum is found. Can we really afford to let this happen when the maternity services are in such desperate need of experienced, skilled midwives?

The clock is ticking and the issue is urgent. I ask my noble friend, who is well aware of this difficult issue—we have met in the past to discuss it—to tell me when the Government are planning to publish their proposals and when independent midwives and other non-NHS bodies will be able to take up the NHS clinical indemnity arrangements planned for by the Government.

[Lord Mawson]

My Lords, I rise to support Amendment 131A proposed by the noble Baroness, Lady Cumberlege. My wife and I have three children and have experienced some choice as to whether they were born at home or in hospital. I must admit that this was not a matter to which my wife and I had given a great deal of thought when we had our first child 31 years ago. Then we naively assumed that having a child in hospital was fine and the normal practice. The doctor would look after us. However, the truth is that it was far from normal for a young married couple. We discovered later that everything that was done seemed to be focused not on the well-being of the patient—my wife and child; some would say the customers—but on the interests and timetable of the consultant. Medication was given that was not really needed to ensure that the child was born to fit some preordained hospital schedule, a timetable that I think had more to do with the consultant’s golfing schedule, I discovered later, than the interests of the mother and child. The experience left some scars.

Our second child was born at home in Tower Hamlets, under a new home birth scheme that was quite radical at the time and which was set up by Dr Wendy Savage. I must say that this experience was completely different. We all felt so much more relaxed and in charge of events, as best you can be on such occasions. It all happened rather quickly and in a relaxed atmosphere and was an experience of great joy for us all. The effects of this experience on mother and child, with a competent midwife present, were quite different. I must say that even I felt quite competent in making the tea. The first experience in hospital had all been about a culture of illness at the most important moment of parents’ lives; the latter was about health and well-being.

Health and Social Care Bill

Lord Mawson Excerpts

Tuesday 11th October 2011 Lords Chamber

[Lord Mawson]

My Lords, I am a social entrepreneur who, for 25 years, has danced with the dinosaur-like structures of the NHS. I have had my feet trodden on many times, as colleagues and I have attempted to bring some innovations into primary care. We know from personal experience how difficult it is to bring about a more integrated service and innovation within such bureaucratic and out-of-date structures. The vested interests in the BMA and elsewhere in keeping things unchanged and unchallenged are considerable. At the same time, a nostalgic view of the NHS prevails which is anti-business, but which fails to recognise that most GP practices are small businesses and always have been. Let us be honest. I, for one, wish the Government well with their difficult task in bringing much needed change to the NHS.

While many colleagues will have a lot to say about the new proposed structures in primary care, I will make a few simple but fundamental points that appear to have been overlooked. In my experience, trying to change very large organisations—in this case one of the largest in the world—takes time and a great deal of patience. It will involve getting behind those more entrepreneurial doctors who embrace innovation and a more integrated view of the world. In the experience of my medical colleagues, the offer of the biomedical model alone in primary care is too limited an approach for the kinds of health needs that are presented daily. A more integrated and holistic approach is needed, one which sees a human being as not just a bio-medical machine but a fully rounded integrated person set within a social context. Yet many GPs who are committed to positive changes and who are working with the Government to attempt to bring them about are feeling bamboozled by the torrent of paperwork that is being thrown at them by out-of-date anachronistic structures which only know one game—the old game.

In a culture where people are increasingly, through the use of technology, living in an integrated world where at the push of a button many choices present themselves, it will be difficult for this new generation of entrepreneurial GPs to create a flexible structure and innovative culture in the NHS, which is still dominated by silos and an ideology of health inequalities—an ideology which sounds very fine in theory but which, in practice, has many unintended practical consequences that do not favour the patient.

The entrepreneur Steve Jobs, founder of Apple, who has just died knew that technology can be the way into culture change and his technology has created a wholly new generation who no longer want silo-like responses to their problems but at the touch of a button to find an integrated solution.

I would like humbly to suggest a few small simple innovations that the GPs I work with inform me could make an enormous difference to both practice and culture as we seek to push the NHS forward. I have found that the way into large, seemingly immovable structures and organisations, as an entrepreneur, is often through small, simple things that make a big difference. I therefore ask the Minister the following simple, but vital, questions. First, why has the iPad not been used in hospitals and by GP practices and district nurses as a simple integrated communications tool? Secondly, why is it that a GP in Tower Hamlets cannot Skype a consultant in the London Hospital with the patient by their side? Everyone is increasingly using Skype in the real world to communicate and it is free. My medical colleagues tell me that 99 per cent of their patients see no problem with confidentiality rules. We need to remove a system and ideology that makes simple, obvious tasks so complicated. Thirdly, why is it that chest X-ray forms are different everywhere you go in the country. Why are they not uniform and available everywhere online? Fourthly, why have neither the Department of Health nor NICE produced a standard referral form for all types of referral to hospital?

I am a great supporter of the Government’s decision to go local, but as an entrepreneur I know, as do my GP colleagues, that there is a whole raft of things that do not need to be developed in every part of the country. It is too expensive and unnecessary. I am told that there is a whole raft of rules stopping the modernisation of the NHS. When innovators like me attempted to cut through these rules in east London in some of the poorest housing estates in Britain, I was told by some at the time that the sky would fall in. It did not and the offer to patients improved. This institution desperately needs innovators, not more bureaucrats.

My colleagues and I are attempting at this time to build a new health centre in one of the most difficult housing estates in London—and here I must declare an interest—which is part of an integrated project on a particular estate that includes both a new school and 500 new homes. Every key partner is supporting the project but it is the outdated, overly bureaucratic systems and processes of the PCT that are simply getting in the way. There are some good people in this PCT, but I cannot imagine how they keep their sanity in such structures. I know this is a widespread problem as many people are retiring early across the country and there is far too much sick leave in the NHS. Ill structures make people ill.

How do we make the simple things happen that catalyse the changes that are necessary and make it worth coming to work for? How do we modernise the NHS and give GPs the tools to do it? I suggest that some of this is about enabling them to just use the simple tools of technology that you and I use every day. It is about giving civil servants permission to get behind innovators.

I would like to leave your Lordships with a final clue. Steve Jobs at Apple did not go around asking all his customers what they wanted. He did not consult them to death. He believed that if the product was good enough for him, it was good enough for them. The real test for those who oppose this Bill is: would you walk into the average inner city London GP practice and register yourself as a patient? Would you as a patient rank the quality of care provided there as high? If the answer to these two questions is no, then you need to embrace change within the NHS. Jobs achieved what few politicians do. He embraced entrepreneurship and innovation and created real and sustainable change. He focused on creating small innovations in technology that worked well, and then offered them to the world. On his sick bed, he showed a commitment and attention to detail that I have yet to see in many politicians and civil servants. The easiest way into the NHS impasse is simply to back those GPs and nurses who are not threatened by this new emerging world but who embrace it and grasp it with both hands.

We must back the innovators with a sense of purpose. Learn from those who make change happen. Is change going to be difficult? Will this Government get some things wrong? Yes. Innovation is always like that. The question is: can the organisation learn from mistakes? Can it learn by doing? Can it start walking instead of talking? You cannot hold back the ocean; let it flow.