NHS: Long-term Sustainability

Lord Parekh Excerpts

Thursday 18th April 2024 Lords Chamber

[Lord Parekh (Lab)]

My Lords, the NHS is neither a leader nor a laggard, as shown in a comparative study of several countries. I think that broadly captures what many of us feel about the NHS. It embodies some fine values, such as equality of treatment, being free at the point of delivery of service, a strong incentive to regulate expenditure, and maintaining the self-respect and confidence of individuals that when they are in trouble they will be looked after and not have to worry about payment. All these are great virtues that the NHS embodies.

Sadly, it is also the product of its time. If you cast your mind back to 1948 and what followed afterwards, one begins to see an authoritarian culture where the experts know what is best. This is the ethos that is embodied in the culture of the NHS. For example, you can have a long waiting time and people do not see anything wrong with it, or no choice of the consultants or doctors you will see—it is decided for you—or your path to the consultant is already heavily guarded and not something that you can choose. There is poor investment in staff and diagnostic technology, so that you have machines for MRIs, CT scans and other things lying idle because they are supposed to be used only during working days. For all these reasons, we have reached a situation where the NHS does a lot of good and embodies a lot of good values but does a lot of work that many of us regret.

The NHS needs to be improved—radically, in some respects—and the question is not simply how we can maintain its sustainability; the question is whether we want to sustain it in its current form, what other changes we want to see made and whether those changes can be sustained over a period of time. I shall share my thoughts on this briefly.

The British people by and large cherish the NHS but not uncritically, which is why when they begin to discover its defects they increasingly become critical of it. Some 24% of people are heavily alienated from the NHS, and that number is increasing. That should be a source of concern to those of us who value the institution.

So how do we maintain the NHS? How should it be funded? We have relied on taxation as the source of revenue, and it is right that we should do that. I do not have time now, but I argue that compared to, for example, social health insurance or personal health insurance, taxation is a much better way. It gives the individual a sense of ownership of the organisation—he feels that this is his organisation because he has paid for it, and so on. Naturally, though, taxation is subject to party conflicts and divisions, and is never going to produce enough.

The revenue that taxation brings therefore has to be supplemented by other sources of revenue, but what other sources are available to us? There are two: reducing costs and increasing income in the NHS. When it comes to reducing the cost, one can think of a variety of ways in which expenditure could be cut. Lots of work is being done, for example, on why medicines for patients are lying unused—they are used for a day or two while the ailment lasts and then they are completely forgotten, and eventually wasted and thrown away. There are ways in which you can use electronic technology to alert the patient that it is time for him to take his medicine, and various ways in which you can control that.

On raising revenue, I was told by several people who have worked in this area in the United States and elsewhere, “Why don’t you have research, so that you have people who work with the NHS providing abundant data, with the state having access to these people and these diseases? Why don’t you have research done on this, resulting in innovations of medicines and instruments that can then be marketed?” It is not impossible for the NHS to think in terms of research scholarship.

I should have thought there were ways in which the NHS’s revenue could be increased and its expenditure decreased. That is the goal towards which the British public themselves seem to be moving. The NHS should be based on the principle of social solidarity but also have introduced into it the principle of personal responsibility.

NHS: Performance and Innovation

Lord Parekh Excerpts

Thursday 15th June 2023 Lords Chamber

[Lord Parekh (Lab)]

My Lords, I thank the noble Lord, Lord Scriven, for introducing this debate.

The NHS turns 75 in July this year. Right from the time it was born, it has been based on a simple principle: it is funded by tax and free at the point of delivery. Over the years, it has become an integral part of the British way of life and has even come to be called a national religion. I share this degree of confidence in the system. However, at the same time, as anyone who has turned 75—as I have—can say, things do begin to go wrong and memory begins to play tricks. I want to use this opportunity to look at the NHS over the last 75 years and say something about the way in which institutionalised memories have begun to fail, how things have begun to go wrong, and why, unless we do something drastic, we might end up regretting its demise. I will itemise five or six major criticisms of the NHS so that the Minister can reply to each of them separately.

The first striking thing about the NHS is that it is hospital centred. Half of all the GP appointments and 70% of the in-patient bed days are taken up by those with long-term conditions such as diabetes and others. Those people are best treated by GPs and nurses, yet only 8% of the NHS budget goes to general practice and community care. If one looks at the allocation of resources, far more resources go to hospitals than to GPs or community care, and one fails to see the point of that.

The second criticism I have of the NHS is that it is not only hospital centred but sickness centred. It is not the National Health Service but the national sickness service. It is supposed to cater to sick people. We are, for example, the third-fattest country in Europe, and an obese person costs twice as much to treat as one who is not obese, yet very little is done to encourage the positive health of the people of this country. We should be concentrating on encouraging people to maintain good health and to exercise and eat well—all sorts of things—not just treating illnesses that result from the failure to do this.

My third point is on the use of medical technology. It is very striking, for example, that ours must be one of very few countries where X-ray machines and CT scans have, at least until recently, not been used on a Sunday, or even Saturday, or public holidays. When I was in the States, it was quite common to get an appointment on a Saturday or Sunday, when those machines were in use.

My other point is about the distribution of money. I have already talked about the distribution of money between GPs—primary care as opposed to hospitals—but there is also the way it is done among the medical profession itself. I have been critical of the merit promotion system, and I have asked Ministers to explain to me the logic of it. In no other profession do you get the merit promotion system. If I get a Nobel prize in literature tomorrow, my salary will not automatically go up, nor will I get an extra increment. Why should doctors be able to get merit-based promotions: merit based on what? Merit is simply a part of what they are supposed to achieve anyway. I am told that merit promotion is not a question of just a few hundred pounds: the budget comes to quite a lot. The question is whether that money could not be used for other purposes.

There is also the danger, as is quite often pointed out, of overmedicalisation. There is sometimes what is called disease-mongering, a phrase that was first used in 1992. Imagine that a disease is invented because certain symptoms are not easily explained. The pharmaceutical industry has a vested interest in inventing diseases and getting people worried about them. Repeat prescriptions keep up the supply of medicines even when they are not used, and there is what is called defensive medicine, whereby doctors keep doing something because they are supposed to be doing something rather than doing nothing. Professor David Haslam has pointed out many of these things in his new book, Side Effects.

I have a couple of other points. I have often wondered about the poor co-ordination between GPs and specialists in hospital. There is a hierarchy between them which I had not noticed, and a hierarchy that means that hospital specialists carry a greater degree of authority than the GP. I have faced cases which puzzled me, when a hospital specialist would recommend a particular medicine, my GP would follow his advice and I would say, “Look, doctor, I don’t think this is right, because this has been given to me once in the past and it had an adverse effect”, but the doctor would say, “I can’t disregard what the specialist has said: he is my superior”. The result was that I had to pay the price for taking a drug which I should not have taken. There are cases where the hospital specialist’s authority is supposed to be unchallenged.

I have often wondered why, in order to go to a hospital specialist, I need to go through the GP route—why I cannot go directly. When the hospital specialist sends in a report, it comes to me via my GP. It takes days to arrive, when a copy could be sent to me directly. Again, from experience, there have been recent cases when I saw a specialist and I should have had the report, but I am still waiting for it because it will take days and days to travel to me.

My last, important point is that there is too much distance between hospital and the local community. The hospital is generally not in direct, regular contact with the local community. It is a separate place where you are sent by your doctor, or you go yourself to accident and emergency. There is no regular interaction between hospital staff and ordinary members of the community, there are no common social events which bring them together, there is no sense of identification by the local community with the hospital, and the result is quite obvious. I have asked for some statistics. It is very striking, when people make their will, how much of their money is directed to the local hospital. The answer is: very little. Why is it that hospitals do not come into the category of those to whom you would leave your legacy? You could leave your legacy to the school or the university, but rarely to the hospital because, unlike schools and universities, hospitals are not seen as an integral part of the community. There must be some way in which hospitals can become an integral part, taking an active interest in promoting the culture of good health within the community.

Broadly, my suggestions are meant simply to accelerate the regeneration of the NHS, because I do not think we can wait too long before the current situation creates a crisis.

Queen’s Speech

Lord Parekh Excerpts

Tuesday 22nd October 2019 Lords Chamber

[Lord Parekh (Lab)]

My Lords, unlike most of my colleagues here, I want to address the question of culture, which forms part of the debate. I want to ask very briefly how our public culture has been profoundly distorted by the controversy surrounding Brexit and the way in which it has been formulated and pursued.

Historically, we have been a liberal democracy in the sense that liberalism had the upper hand and set the framework within which democracy was articulated. Over the years, we have moved in the opposite direction where democracy has the upper hand and lays down the framework within which liberalism should be pursued. When democracy has been detached from liberalism in this way, it comes to be equated with crude majority rule. So democracy stands for majority rule, and we are told that in a democracy majority opinion—the will of the majority—must be respected and not to do so is to be a traitor to democracy. That kind of thing can work at the level of elections, where people vote on a wide range of issues and it is difficult to pinpoint people’s opinion on this or that matter. However, when we conduct a referendum, the situation becomes very difficult because people vote on a specific issue and their differences are expressed publicly.

That is what happened in 2016. Brexiters had a majority, remainers were in the minority and the argument was that the voice of the majority must be respected. The difficulty there was that remainers felt that they were politically disfranchised and that their vote counted for nothing, because even though they secured 48% of the vote, it amounted to nothing because Brexiters had the full gain to themselves. So what resulted was triumphant Brexiters and rather subdued remainers, who felt slighted and diminished.

The other problem associated with this issue is that the two sides have little respect for each other. For remainers, Brexiters are a bunch of fools; they are rather backward, not terribly bright and could be seduced by any kind of information provided by the peddlers of the Brexit model. If only they had been provided with better information, they could easily have been won over to the other side. For Brexiters, by contrast, remainers are ruthless, cosmopolitan liberals with no love for the country in which they live—they have no sense of patriotism. So the result is that we have two sharply defined groups with precisely articulated differences along these lines.

This polarisation between the two groups is particularly acute because of the issues involved, including British identity and British independence or sovereignty. What is Britain, really? Is it or is it not European? Since the question goes right to the heart of what Britain is, therein lie very powerful emotions, with the result that the Brexit controversy has virtually monopolised the entire public debate. There is hardly an area of life where the Brexit/remain division does not infiltrate.

The result of this kind of polarisation, with two groups facing each other, has been the following. First, the two groups have very little in common and cannot even talk to each other. Secondly, each group is self-righteous and, as a result, contemptuous of the other. Thirdly, each group thinks that the other is deeply misguided and is misleading the country and so, in that sense, is a traitor. Fourthly, it has created new identities. I am not only an Indian or an academic; I am also a Brexiter or a remainer. In other words, it has created a new generalised identity under which people can be subsumed. The media have also been highly polarised, and no space has been left for impartial assessment.

More importantly, the polarisation has extended to the very structure of our democratic way of life. What is democracy? Is it all about majority? What is the relationship between the people—the electorate—and their representatives? Should the representatives simply reproduce what the electorate want? Therefore, the crisis of culture I am talking about extends not only to specific issues but to the very fundamentals of our political system.

It is no less important to note that this kind of polarisation has, sadly, distorted our political discourse. It is suffused with the language of “traitors”, “betrayal” and being “ashamed to be British”. Not surprisingly, it has led to physical threats. So questions of civility and scepticism, which have traditionally been characteristic of our political culture, seem to have been thrown out the window. This is the crisis of our culture. As a crisis of culture, it also affects the very bonds that bind people together, it undermines the public realm where impartial discussion can take place and it eats up almost everything that comes in its way.

We must ask: how do we reduce the crisis and resolve it? Equally important is that, even when it has been resolved, it is not going to disappear and the consequences will continue to haunt us. Like so many others, I suggest that, like a tsunami, Brexit has flooded all of our major institutions and forms of language, so it is important to take this question very seriously and give it the importance it deserves.

The NHS

Lord Parekh Excerpts

Thursday 5th July 2018 Lords Chamber

[Lord Parekh (Lab)]

My Lords, I am prepared to loan the noble Lord a second of my time.

I thank and congratulate my noble friend Lord Darzi on introducing this debate so beautifully. Having only three and a half minutes to talk about the NHS, I shall simply say that the NHS is a product of its time. That is very important to bear in mind, because the fact that it was born in 1947-48 penetrates its inspirational principles as well as its structure.

On the division between healthcare and social care, healthcare is free at the point of delivery, whereas social care is means tested, and that binary division is itself a product of its time and was introduced into the structure. There is also a distinction between physical and mental health. When the National Health Service was created, it should have meant the national physical and mental health service, but it tended to mean physical health. Mental health was added later and has enjoyed a Cinderella status; it has not enjoyed parity of esteem in the National Health Service.

My first point is that these various strands that the NHS has inherited have to be integrated, but the question is about how you do that when they are moving in different directions. We need to integrate but in a manner that respects the differences between the strands.

The second way in which the NHS has historicity is in the role of the GP. The GP began as a family doctor—an old tradition in this country—but he is now a gatekeeper. There is a division between the GP and the hospital, and that division also affects the relationship between the GP and his patients.

The third important feature of the NHS that is worth noting is that it began as a highly centralised institution. Those were the days of centralisation, with everything done from the centre. Now, there is an increasing realisation that that is not the way to deal with many of the problems, because problems are localised and so are the solutions. How do we move from a centralised to a decentralised structure? It is not just a question of decentralising an already centralised structure; it is a question of designing it from below and asking fundamental questions.

Here, I want to emphasise the important distinction between the way in which the NHS was conceived, based on excellent principles, and the way in which it has developed certain flaws. Some flaws are adventitious; others are structural, and the structural flaws need to be addressed very carefully—the fact that many of our doctors leave the NHS and leave the country rather than stay here; the fact that there is low morale; and the fact that hospitals are structured in such a way that the management takes over and the doctors count for very little. Those are some of the flaws. Therefore, while we celebrate the achievements of the NHS, we will celebrate them more sincerely and honourably if we are also alert to the weaknesses that it has developed.

When we talk about what we should do for the next 70 years, I simply urge a note of caution. Given the way we have tried to change it over the years, if we can get it right for the next 20 years, I shall be more than happy. Due to the way in which mental and physical health problems are distinguished and new insights into medicine and human health appear, there will be new questions, new divisions and new ways of organising our hospitals. In the light of that, let us think of the next 20 years, rather than the next 70.

The Long-term Sustainability of the NHS and Adult Social Care

Lord Parekh Excerpts

Thursday 26th April 2018 Lords Chamber

[Lord Parekh (Lab)]

My Lords, I too begin by congratulating the noble Lord, Lord Patel, and his committee on this report on the long-term sustainability of the NHS and adult social care.

When Lord Beveridge submitted his report, he told his 26 year-old research assistant, Harold Wilson, the following:

“From now on, Beveridge is not the name of a man; it is the name of a way of life”.


It is important to bear that in mind. The NHS was supposed to embody a particular way of thinking and living. The way of living was based on three major values: first, wherever there is human suffering it needs to be redressed; secondly, it does not matter whose suffering it is; and, thirdly, redressal of the suffering is the responsibility of the entire society. In other words, relief of suffering, equality and solidarity are the three great values represented by the NHS.

In so far as these values are represented by the NHS, it is rightly loved by the country; it is almost a part of our religious practice. One hopes that the entire society will be based on these values but the NHS implies that, even if the rest of society is colonised by other values, it will be an island where these values are worshipped and cherished.

I want to explore what has happened to these values over the past 70 years. There was never an idyllic stage where everything was fine and dandy. I remember that in olden days there were all kinds of complaints about the NHS: for example, its hierarchical character, where consultants would behave like local potentates, and the way in which junior doctors were exploited—all kinds of things happened. Over the years, in some respects these things have changed for the better and in other respects they have changed for the worse.

If we look at the situation now, we begin to see many problems, structural and functional. Morale is low—people are leaving the country or retiring early—and I am told there will be a shortage of about 10,000 GPs by 2020. There is also a wastage of medication and equipment; a wastage of time by asking people to fill in all kinds of forms; and a wastage of money by employing management consultants who contribute little to the working of a hospital. The NHS is also perceived as rather remote. The patient has no direct contact with the consultant, and the GP’s contact with the consultant is intermittent.

With all these things going on, a radical rethinking is needed on how we should structure and fund the NHS and whether its role in a society like ours is consistent with the three values that it represents. It is in this context that one should look at the report of the noble Lord, Lord Patel. I am impressed by the amount of thinking that has gone into it and I wish to use the next two or three minutes that I have to contribute to that thinking and take it a little further.

I cannot do that at all levels but I shall try to do it at two levels. One concerns the financial side of it. In this country there are fewer hospital beds, doctors and nurses than the OECD averages. Obviously more money is needed. That money can come only from general taxation, for the kinds of reasons the report explains. However, there will never be enough. The demand is insatiable: the population will continue to age; new technology will continue to appear; and new medicines will emerge in the market. For all these reasons, there will never be enough money and we will have to find new ways of raising it.

Here I am reminded, having been a university professor, of the way in which universities were asked to diversify their sources of funding. Over the course of years they came up with various answers and perhaps some of them will be applied across the board. For example, there could be major endowments by individual donors. My university has recently been the beneficiary of a gentlemen donating about £2 million.

Secondly, the university has increasingly begun to wake up to the importance of cultivating the alumni culture. There is no reason why hospitals cannot similarly cultivate individual patients—those whose children have been born or those who have benefited from hospitals—and encourage them to contribute to the work of the hospital. In this way, one can give the local community a stake in the NHS. The NHS is not simply seen as a national tree, planted in the middle of an area; rather, it grows out of the area and has organic ties with the city in which it is located.

There is also a good deal to be said for research in the NHS, resulting in discoveries, inventions that will be patented. I have seen this happening in the United States; there is no reason why it could not happen here. For example, the NIHR receives money from the NHS, which could then support projects that would result in patents. Those patents could raise money for the NHS.

There is also the question of the amount of medicine wasted. A lot of patients forget to take their medicine. There is no reason why technology for this cannot be developed. In fact, technology is being developed where electronic tags could be attached to medicines so that, at a particular time, the patient is reminded that it is time to take their medicine. The pharmacist connected to the patient can also ring them and tell them that it is time for their medication. In this way, an enormous amount of money can be saved.

Although I do not think that this subject is worth exploring at this stage, I have often wondered about the whole business of merit awards. I cannot see any other profession where people can receive merit awards; certainly there is no chance of someone giving me, a university professor, £10,000 a year, even if I won a Nobel Prize. Doctors get this and I must ask the House to take a second look at why it was introduced, why it is deserved and whether it should be continued in the current climate.

My last point is simple. Ultimately, the report says that any medical institution, such as hospitals and GPs, depends on the good will of individual patients. Patients must therefore not make unreasonable demands on doctors. They should take care of their lives and take charge of their destiny, rather than expecting doctors to take care of them. That kind of individual responsibility must be cultivated and can come only if there is an organic bond between the individual and the hospital or GP. Once we begin to embed a local medical institution in the life of the community, giving the community a sense of responsibility for and ownership of the local health service, things can begin to produce miracles.

National Health Service

Lord Parekh Excerpts

Thursday 14th January 2016 Lords Chamber

[Lord Parekh (Lab)]

My Lords, I thank my noble friend Lord Turnberg for introducing this debate with great wisdom and erudition. While I entirely agree that the principle underlying the NHS is noble and widely acclaimed, in practice it leaves much to be desired.

Noble Lords have concentrated on funding and other things but I want to concentrate on the more elementary aspect of some of the practices that characterise the NHS. It is very striking, for example, that doctors are inundated with paperwork so that they have hardly any time to talk to their patients or spend much time with them. It is also striking that when a GP refers a patient to a consultant, the consultant’s letter does not arrive until about two or three weeks later, either because—so I am told—he does not have the typing facilities or because he would not use electronic devices to communicate with the GP. I cannot understand why this sort of thing should go on in this age.

As we have talked about our ageing population, it is worth bearing in mind that more and more of our people suffer from Alzheimer’s, dementia and other conditions. The result is that they forget to take many of the medications prescribed for them, or for some reason they take it earlier when they feel ill and stop when they begin to feel better. It may be a good idea to remind them in some way from time to time that they have forgotten to take their medication. I gather that some experiments are being done, and there is no reason why the NHS cannot be technologically more imaginative. Why can blister packs, for example, not be devised so that they warn patients at the appropriate time that they should be taking their medication? Or, for example, why should chemists not be able to monitor whether a particular medicine has been taken by a patient and, if necessary, ring them up and tell them they should be taking it? Therefore, technologically, we ought to be able to produce smarter and more sophisticated packages of medication than we do.

My third point has to do with some of the infrastructure of our surgeries, some of which are located in old terraced houses. Doctors would love to provide all kinds of services but they are unable to do so because of the cramped environment in which they have to function. I cannot see why local authorities and other bodies cannot provide purpose-built medical facilities where GP services can be housed. This would mean that GPs could provide the kind of services they would like to and patients would not be cramped and would feel much more comfortable.

My last point has to do with the way the Government have treated junior doctors. Doctors remain our main asset, and if they are alienated and feel resentful they may leave in large numbers, which would be no credit to our society.

NHS: Medical Competence and Skill

Lord Parekh Excerpts

Wednesday 7th January 2015 Lords Chamber

Asked by

[Lord Parekh]

To ask Her Majesty’s Government what steps they are taking to maintain and, where necessary, improve the level of medical competence and skill in the National Health Service.

[Lord Parekh (Lab)]

My Lords, it is an honour and a privilege to introduce this debate. I thank in advance all those Peers who will speak in the debate for the significant contributions that they will make from their respective points of view.

The NHS is one of our finest achievements. No pain goes unrelieved for lack of money. Its staff are dedicated, driven by a sense of calling, and their level of competence is second to none in the world. However, no institution is perfect and it can always do with change. Every institution builds up its own structural biases, and every profession has a tendency to build up a certain ethos, corporate mentality and collective spirit, and tends to do things in a certain way that is useful but has limitations. I suggest that this is just as true of the NHS. That is why several changes have been made over the years, particularly during the last 25 years. I do not care for the changes that are largely managerial and which are concerned to centralise the system and transfer power from doctors to managers. But I greatly welcome the changes that are of a medical nature; for example, appraisal and revalidation of GPs, and the collection and publication of surgeons’ death figures. These changes have been or will be of great benefit to the patients and to the medical profession. It is in the spirit of these changes that I wish to frame this debate and ask two questions.

My first question has to do with the general nature of medical competence in the NHS. How can we sustain the current level of medical competence and skill in the NHS? There is a general feeling that it is being threatened by recent structural and managerial changes. We need to address that concern. Secondly, there is a general impression among the public, the professional staff and the managers that errors of judgment occur in the NHS, and that there are pockets of incompetence that need to be carefully identified and addressed. We obviously need to see whether there is any truth in this impression and deal with it. Sometimes it is denied altogether: that there is absolutely nothing wrong with the level of medical competence in the NHS. That is not true. A report by the Parliamentary and Health Service Ombudsman on 26 November 2014 says that,

“poor communication, errors in diagnosis … and poor treatment”,

top the list of hospital complaints investigated by the ombudsman, Julie Mellor. She upheld just under half of those complaints. Statistical surveys in Australia, the United States, Canada and elsewhere have highlighted what is sometimes called substandard surgical performance. These things occur in those countries and I see no reason to believe that, much as we are better than many of those countries, some of these things do not occur here from time to time.

I was recently reading a wonderful article by the Honourable Geoffrey Davies of the Australasian College of Surgeons in the recent issue of the ANZ Journal of Surgery, in which he talks of an unacceptable level of errors resulting from inadequate competence. In our country, more than 12 surgical specialties collect and publish data on surgeons’ death rates. They show variations and some cause for concern. In all these cases, the concentration is unfortunately on the surgeons. Their errors are easy to identify and difficult to forgive. I suggest that we also look at non-surgical consultants, including physicians and GPs—indeed, the entire medical profession—to ensure that they are of the highest level of competence, for which we are justly famous and for which the medical profession has justly deserved a high reputation.

Medical competence is not about negligence—we know how to take care of that—and nor is it about professional conduct or misconduct. It is about medical judgment: that is, correct diagnosis and correct treatment. It depends not just on the kind of medical degree that one has acquired but on one’s experience and training, on keeping abreast of one’s subject, on giving enough time and attention to the patient, on a sense of accountability for the consequences of one’s diagnosis and treatment, on constant feedback from the patient and so on. Given that these are some of the preconditions of medical competence and the wider feeling that I talked about earlier, I suggest that our distinguished medical professional might like to consider five suggestions. I make them in a tentative spirit, not being a doctor myself.

First, as I said, our surgeons have introduced the practice of collecting and publishing death figures. I suggest that, with suitable modification, the same sort of practice needs to be introduced for consultant physicians. They currently have no means of knowing how the patient responded to the treatment that they prescribed. They are in no position to learn from positive and negative experiences. For example, if a patient goes to see a consultant, a particular medicine is prescribed and if it does not work, the consultant will not know this. The GP picks up the pieces. If the GP decides to refer the patient to the consultant, the consultant may not be the same one that the patient saw in the first instance. It is therefore very important that there should be a measure of continuity between the consultant and the patient. This could be ensured either by the GP informing the consultant as to what his prescribed medicine has done to the patient or, as happens in some countries, through the patient being in contact with the consultant on a regular basis or when the medication does not work as he was promised it would.

Secondly, consultants and GPs are subjected to sometimes unreasonable targets; hence, they are unable to spend as much time with patients as they would like, or as is necessary. This leads to errors of judgment, some of which are very serious. Steps need to be taken to avoid such situations. Targets are important, but should not be unrealistic or at the cost of the quality of care.

Thirdly, GPs are at the centre of the NHS. It is not a secret that patients sometimes avoid certain partners in a practice, even when that involves considerable waiting. There are many reasons for this. One has to do with suspicion of a lack of full clinical competence on the part of certain partners in the practice. It is in the interest of the GPs and the patients that the appraisal system that we have introduced should be made robust. Inadequate GPs should not be covered by an otherwise excellent practice.

The criteria of patient satisfaction should be more carefully defined and include not just “how much time did the doctor give you” or whatever but such questions as how many visits she had to undertake before her complaint was diagnosed or how often her medicine was changed before she felt better. Cases of whistleblowing among GPs and consultants should be viewed more charitably than at present. Whistleblowing is a public service and sometimes a compulsion of one’s conscience. Hence, its occasional excesses or misuse should be condoned or dealt with lightly. If even 1% of our more than 60,000 GPs systematically make a mistake, the extent of harm done to patients is quite considerable. That is also true of consultants. In so far as whistle- blowing diminishes this danger, there is every reason to welcome it.

Fourthly, some cases of incompetence have been identified in relation to doctors who have been engaged by medical companies, on whose resources the hospitals rely. These medical companies need to be monitored and watched more closely.

Fifthly, young doctors sometimes do not have enough clinical experience because of the EU working time directive. The directive is necessary because it protects patients against tired and overstretched doctors. It also allows doctors to learn their craft under ideal conditions. However, training is also important and we therefore need to increase the training period for GPs.

To sum up, I salute the professionalism, idealism and dedication of the medical profession in the NHS. In this debate, I have been concerned to ensure that nothing is done to tarnish the richly deserved reputation of the medical profession, whether it is done by overbearing managers, by target-obsessed civil servants or by a complacent and sometimes defensive profession.

NHS: Seven-day Working

Lord Parekh Excerpts

Thursday 6th February 2014 Lords Chamber

[Lord Parekh (Lab)]

My Lords, I thank the noble Lord, Lord Ribeiro, for securing this debate and introducing it so well. A case for seven-day working in the NHS seems so overwhelming that I am surprised that it has taken us so long to raise it. I can think of half a dozen powerful reasons why seven-day working is an absolute must. As the noble Lord, Lord Ribeiro, has said, it reduces mortality, which can rise by as much as 16% for patients admitted over the weekend. In law—although I have not had the time to get this tested—it would amount to indirect discrimination to suggest that people who are admitted over the weekend receive less satisfactory treatment and invite death earlier than in other cases. That would constitute a case of indirect discrimination.

If we have seven-day working, it will amount to better use of diagnostic machines, laboratory equipment and operating theatres. It will also decrease the patient’s length of stay in hospital and thereby not only reduce pressure on hospitals but increase GDP because people will come out of hospital earlier and be able to work more days. The amount of patient satisfaction would also be considerable. For all these reasons, a case for seven-day working seems compelling.

I add an extra reason to assist the Minister in his negotiations with doctors who might resist this, but it is not the comparison with retail traders opening on a Sunday, as that is not a good analogy. We ask that our hospitals be open over the weekends, and that consultants and others be available, because these are issues of human lives. Where human lives are concerned, you cannot make a distinction between a weekend and a weekday.

Given that the case is so overwhelming, what are the objections? I hear three objections from many doctor friends who I am privileged to know. First, I am told it will impose extra burdens on consultants and senior clinical staff. The answer to that is, first, it need not be so because the workload can be properly distributed. Secondly, the same doctors who talk about the extra burden have absolutely no difficulty attending private clinics and private hospitals where they perform operations over the weekend. That is an argument of self-interest, which does not wash with me.

The second argument is that it will increase the cost. It could, and we have had figures bandied about. To that, my answer is: first, if you have better rota and shift planning, you need not employ a large number of extra consultants or senior clinical staff. You will also reduce the patient’s length of stay in hospital, which would mean a considerable saving. Hospitals under the same trust should be able to share clinical staff, so it does not necessarily mean each hospital having its own extra consultant. Equipment could be more effectively shared—that would mean a considerable saving—and, of course, there will be a reduction in the current payments for unusual hours that are paid to doctors. For all these reasons, I think that the objections based on cost can be addressed.

There is a third objection that many of my friends have made, which is that it could be hard on women. The noble Lord, Lord Ribeiro, said that many women consultants and others might welcome working over the weekend; but there are also many others who would find it difficult to work over the weekend and might resent being compelled to work in exactly the same way as their male colleagues would. There again, talking to consultant friends, I am told there is an answer: better rota and shift planning so that women need not necessarily be involved over the weekend. I suggest that there are enough reasons to go ahead, full steam, with this project.