Health and Social Care Bill

Lord Patel Excerpts

Monday 7th November 2011 Lords Chamber

To conclude, the mobilisation of health and well-being boards behind the concept of a fairer and more equal health service is an absolutely crucial potential we all need to help realise.

[Lord Patel]

My Lords, I support these amendments and I have my name on two of them. I particularly associate myself with the comments that the noble Baroness, Lady Williams of Crosby, made on the need to address the issues within public health to reduce inequalities.

We must all be very encouraged to see the recommendations of the Health Committee in its report of 2 November on public health. One of the recommendations says:

“We do not understand why the Secretary of State’s new statutory duty to reduce health inequalities under the Bill appears to apply only to the exercise of his functions in relation to the health service. We recommend that the Bill be amended to make it clear that the Secretary of State’s duty to reduce health inequalities applies in the exercise of all his functions, including those applying to public health”.

The noble Baroness, Lady Williams, already referred to the inequalities in health that occur because of lifestyle-related diseases. In previous discussions we have noted that 40 per cent of acute admissions are related to lifestyle-related diseases. It must be right that the statutory duty of the Secretary of State includes functions relating to public health.

[Baroness Greengross]

My Lords, I will speak to Amendment 33 in my name. I am pleased to follow the noble Baroness, Lady Williams, and the noble Lord, Lord Turnberg, because a lot of my work is concerned with the sort of inequalities they have spoken about. The noble Lord, Lord Turnberg, mentioned Professor Sir Michael Marmot. I have been privileged to chair the advisory group for the longitudinal study on ageing that he established. I have done that since it started. It demonstrates so clearly the terrible, almost life-or-death sentences that health inequalities impose on different groups in terms of their life expectancy. This is really something that is quite impossible for us to continue.

My other role as the lead commissioner on age at the Equality and Human Rights Commission means that I hope very much that we can, if we amend this Bill, achieve more positive healthcare outcomes. The Bill, in order to achieve that, must be explicit that improvements have to be achieved across the whole population, not just some parts of it. We know that one group whose needs are currently very often underprioritised and underrecognised is older people, particularly within the NHS. Sadly, ageism persists in clinical practice—very often older people lag behind other groups in terms of better healthcare outcomes. I am very concerned that unless a clear obligation to demonstrate that improvement is being achieved across the whole population, the specific needs of older people will continue to lag behind those of other groups or sometimes to be ignored and similar existing health inequalities may even be maintained and strengthened.

My amendment would define the Secretary of State’s duties to reduce health inequalities against three different criteria: the definitions of equality contained in the Equality Act 2010; different parts of England; and different socio-economic strata. In any subsequent reporting of progress towards reducing health inequalities, the Secretary of State would have to demonstrate consistency in the progress made against the three criteria.

My amendment would clarify the Secretary of State’s duties in relation to reducing health inequalities. I am afraid that without this in the Bill health service improvement may not reach everyone. There may be a failure to improve services for specific groups such as those mentioned within the list of protected characteristics. Clause 3 currently requires the Secretary of State to have regard to the need to reduce inequalities between the people of England with,

“respect to the benefits that they can obtain from the health service”.

The amendment to this clause would ensure that access to health services and improving health outcomes were an intrinsic part of the Secretary of State’s duties. Without guaranteeing improvement in access to services, there is a risk that there could be high levels of variation in the kinds of services the NHS provides across the country.

I have listed the equality characteristics detailed in the Equality Act 2010 which is not necessarily Members of your Lordships’ House. Too often it has been the case that health inequalities exist in part because people belong to one of the groups listed here and there is actual discrimination against a patient. In relation to specific treatments, patients are treated differently not purely on the basis of clinical decisions but on the basis of one of the protected characteristics, particularly age. For example, despite improvements in cancer outcomes, a 2007 study of breast cancer patients in Manchester found that older women are less likely than younger women to receive “standard” management for breast cancer and less likely even after accounting for differences in general health and co-morbidity to have surgery for operable breast cancer.

My amendment will ensure that the Secretary of State’s duties are clear and specific and that people across England can be sure their access to healthcare and the quality of the healthcare they need will be assured regardless of who is providing the service. The areas where the Secretary of State can demonstrate improvement in reducing inequalities should be balanced and fair in their focus. The risk otherwise is that commissioners will be incentivised to invest their efforts in improving health outcomes for those groups where they believe they can make the easiest and quickest gains and some groups, including older people, risk being shunted to the sidelines. This must not happen.

Health and Social Care Bill

Lord Patel Excerpts

Monday 7th November 2011 Lords Chamber

[Baroness Armstrong of Hill Top]

I intervene to dispel the view that it has always been even and equal for private and non-private patients in the NHS. When I was an Opposition Member of Parliament, before the 1997 election, the largest complaint that I had, which I had regularly, surgery after surgery, was from people who had some serious condition. They had eventually got in to see the consultant, frequently having had to wait a long time. Then they were told, “Yes, you need an operation but the waiting list is 18, 20 or 24 months. However, if you come in to see me next week in my private practice, I can do the operation in two weeks’ time”. People found that offensive.

That is why, during the passage of the Bill on foundation trusts, there was outrage on the Back Benches that we were going to revert to the situation where it seemed not to matter whether people were public or private patients.. That came because Back-Benchers insisted that they did not want to return to the old system.

I am actually in favour of varying the cap and the noble Lords who tabled the amendment actually had the right idea. But for us to pretend in this House that there was once a glorious age where everyone was treated equally is quite honestly offensive to all those people who knew that they were getting a poor service and were not getting adequate access to the healthcare they needed and had the right to receive.

[Lord Patel]

I rise briefly to comment on this amendment. As far as declaring an interest is concerned, I have not seen private patients because my contracts were such that academics did not do private practice. I have a family member who is a consultant. My daughter is a consultant at the Marsden where I hear there is a high percentage of private patients. I have no idea whether she does private practice or not. I have not seen any benefits of it. Maybe they will come.

However, I remember when I was a student and was training in King Edward VII Hospital in Windsor, in Ascot and other places there were private wings in the same hospital. Yes, the care provided was equal for NHS and private patients. However, one difference today is that NHS patients now receive quite a significant part of their care provided by doctors in training. If we are to ask for equality in how patients are looked after, we must say not only that those patients in private wings cannot jump the queue but that there must be the same quality of care provided by all the medical staff who work in the NHS.

I have one other question, which I would like to put to the noble Lord, Lord Phillips of Sudbury. How would we manage his amendment when there are to be qualified providers, which might provide care not only for NHS patients but for private patients under their own terms and conditions? How would we manage those qualified providers to ensure that they behave in the same way in dealing with NHS patients?

[Lord Phillips of Sudbury]

On the question addressed to me, I do not know whether I can give an off-the-cuff precise answer to the noble Lord, but my apprehension is that, in NHS hospitals with private facilities or a private ward, there is an attempt to deliver comparable clinical care to private and NHS patients. As the noble Baroness has just said, there are cases where that plainly does not happen, but that is the ideal and it is achieved in many hospitals—I suspect that the Royal Marsden is one of those. All that the amendment seeks to do is to put that ideal into the Bill so that it is also law.

I do not want to waffle on now about the delivery of that ideal in practice—I say “waffle” because what I would say might not be impressive to you gentlemen who are treading the wards—but I believe that it is possible and can be done. I am encouraged by my three co-signatories to the amendments to believe that this can be done and delivered. As I said, that may require an amendment to the provisions of the Bill that deal with Monitor so as to give Monitor an explicit role in policing this requirement of equality of clinical treatment and care.

Health and Social Care Bill

Lord Patel Excerpts

Wednesday 2nd November 2011 Lords Chamber

[Lord Patel]

My Lords, my name is on the amendment and I am pleased to support it. Before I say what I wish to say, I declare an interest as an honorary fellow of the Royal College of Psychiatrists, an honour bestowed on me by the noble Baroness, Lady Hollins, when she was the president of that college, having been introduced in glowing terms to her by the noble Lord, Lord Alderdice—exaggerated glowing terms, I may add.

Noble Lords may wonder why I received that honour—and so do I—but I remember that at the time I was for several years chairman of the Clinical Standards Board for Scotland. It was during that time that I recognised that the provision of services for mental health was quite appalling compared to the services for physical health. It was through writing of standards for illnesses such as schizophrenia, to which the noble Baroness referred, that I discovered how appalling the situation was, not only in the environment where the care was delivered but in the care itself, and how that led not only to limitations in care but to limitations in resources for research and other end-producing standards.

It was of interest to read:

“Everything in my portfolio straddles the interface between health and care—mental health, social care, long-term conditions, cancer. Take for example mental health. The interdependencies between good mental health and good physical health are clear. Mental health sits at the point where health, social care and public health intersect. Delivering better outcomes in physical health will require mental health to be given parity of esteem. So that both mental and physical health problems get equal recognition in the commissioning and delivery of health and social care”.

These are not my words but the words of Mr Paul Burstow, the Minister of State for Health.

“Parity of esteem” is not defined in the document. However, it would be reasonable to expect that this would mean recognition of the equal importance of mental and physical health. Perhaps the Minister will help us with a definition so that we clearly understand what is meant by parity of esteem. You would expect this recognition to be evident in terms of access to mental health services; funding for services proportionate to the disease burden; and mental health being equally at the forefront of the minds of the new clinical commissioning groups and structures.

Sadly, however, this is not the case. For example, for a young person with a physical health problem such as diabetes, to which the noble Baroness referred, who is nearing an age where he is about to start receiving his care in an adult service setting, none of us would expect there to be any problem or difficulty with this move. However, consider a young person with a mental health problem about to make the transition to adult mental health services. Recent research indicates that as many as a third of all the young people who arguably needed continuing care did not make this transition. These young people fall into a gap that would not be acceptable in physical health care. Furthermore, even where a service is available, only 5 per cent of young people experience an ideal transition.

Next, consider the disease burden that is attributable to mental illness. Mental illness is a cause of suffering, economic loss and social problems. It accounts for over 15 per cent of the disease burden in developed countries—more than that caused by all cancers. In the UK, at least 16.5 million people experience mental illness. Despite this burden, a proportionate allocation of funding to mental health services often does not reflect that personal and economic scale. Nationally, some 12 per cent of the total NHS budget is allocated to mental health. While it is difficult to call for increased expenditure in the current economic climate, there is clearly a need.

There are clear benefits from mental health being regarded as the same as physical health. For example, poor mental health is associated with the increase of diseases such as cardiovascular disease, cancer and diabetes, while good mental health is known to be a protective factor. Poor physical health also increases the risk of people developing mental health problems.

The amendments are therefore appropriate. They will ensure that the Bill enshrines the principle of equality of physical and mental health in law so that commissioning bodies know their responsibility to commission high-quality and continuously improving mental health services, as they do for physical health. That commissioning bodies have such a responsibility can in no way be assumed from the present wording of the Bill. While it places a duty on the Secretary of State, the NHS Commissioning Board and the clinical commissioning groups to promote comprehensive health services in respect of both the physical and mental health of the people of England, the Bill makes no specific mention of mental illness with respect to their duty to the improvement in quality of services. It refers simply to the prevention, diagnosis or treatment of illness. I support these amendments and hope that other noble Lords will do the same.

[Lord Patel of Bradford]

My Lords, in speaking in support of these amendments I declare that I was formerly the chair of the Mental Health Act Commission. I have a long-standing interest in working to promote better mental health and in particular how we can best improve quality and outcomes in services. I echo what the noble Baroness, Lady Hollins, and the noble Lord, Lord Patel, have said and shall try to put a little bit more flesh on the bones.

It is clear to me from my work over the years in this area that we cannot and should not try to separate physical and mental illness. The separation of mind and body has been the focus of philosophical debate for many years but it is obvious to anyone who has at some time been unwell that physical problems have a profound impact on our mental well-being and that being unwell from a mental illness has profound impacts on our physical well-being. To quote the great American author and thinker, Henry David Thoreau:

“Good for the body is the work of the body, good for the soul the work of the soul, and good for either the work of the other”.

I could cite a great many examples that demonstrate that truth. As the noble Lord, Lord Patel, said, compared with the general population, people with depression are twice as likely to develop type 2 diabetes, three times more likely to have a stroke and five times more likely to have a myocardial infarction. Approximately 10 per cent of people have serious depression, but this rises among those with cerebrovascular disease, where rates of major depression are twofold. Among those with diabetes or cancer it rises to threefold, and among those with recurrent epilepsy it can be as high as a fivefold increase. In fact, living with a physical illness can adversely affect our relationships, causing isolation and anxiety, which can be just as debilitating as the physical illness itself.

Apart from the obvious common sense of these amendments, I am keen to see them passed because there is a need to bring these issues to the fore. Mental illness has for far too long been perceived as a Cinderella service lacking the serious attention it needs as part of a fully integrated health service. By creating parity between these twin aspects of our well-being and health, we can ensure that the improvements in quality that we all want to see are realised that much more effectively. In fact, I would go as far as to say that this is one of the single most effective things we could do to bring about these improvements.

By emphasising parity in health and mental illness for the Secretary of State, the clinical commissioning groups and the NHS Commissioning Board, we will see some very tangible benefits. For example, we could see a broadening of the Government’s health inequality agenda so that their indicators of disadvantage include mental illness and learning disability. The Royal College of Psychiatrists and the Disability Rights Commission have called for that. That would also help ensure that clinical commissioning groups seek improvements in health through the inclusion of mental illness in the annual health checks undertaken by GPs.

The implications for improvement in commissioning are profound and speak directly to the stated aims of the Bill: that is, continuous improvements in health and in the quality of services. While it is correct that the Bill calls on the NHS Commissioning Board and clinical commissioning groups to promote a comprehensive health service with,

“respect to both physical and mental health”,

there is still a need to be absolutely clear about the need for parity of esteem in physical and mental illness. This is not clear from the Bill as it stands. As the noble Lord, Lord Patel, said, it simply refers to,

“prevention, diagnosis or treatment of illness”.

That is likely to perpetuate the current imbalances which exist with respect to mental illness services and needs. For example, we currently spend approximately 12 per cent of health and social care expenditure on mental health services. The actual burden of disease is as high as 20 per cent when taking account of all disability adjusted life years. Bear in mind also that there will be only one secondary care specialist on the clinical commissioning group boards, who in all probability will be a representative from the physical health services. This amendment does not mean that there should also be a representative from mental health services but it will ensure that the clinical commissioning group is absolutely clear that it must commission equally high- quality and continuously improving mental health services.

By ending the unhelpful dualism between mental and physical health that has so characterised our services, we will see a holistic approach to health and healthcare. At the same time we will start to end the stigma that so many people have lived with and that has been the cause of so much misery and lost opportunities to help people be well. I am sure all noble Lords will agree that the stigma attached to mental illness has caused service users and their families a great deal of harm. I am pleased to say that public attitudes to this have been changing. In the 2011 Attitudes to Mental Illness survey, the percentage of people agreeing that,

“mental illness is an illness like any other”,

increased from 71 per cent in 1994 to 77 per cent this year. We should continue to support this positive trend in attitudes by emphasising the parity across mental and physical illness as these amendments seek to do.

The statistics show that this is not just a technical or even a semantic issue. The potential benefits are profound. In the same attitude survey, we learn that only 50 per cent of people would feel comfortable talking to their employer about mental illness and nearly a third said they would not be comfortable talking to a close family member or friend. The trends are moving in a positive direction compared to previous years but I am sure noble Lords will agree that we still need to do a great deal more to ensure that people are able to access help quickly and appropriately. Parity between physical and mental illness is one way in which we can strengthen that process.

I know that the Minister is a great supporter of issues related to mental health. I hope that he will support these vital amendments.

Health and Social Care Bill

Lord Patel Excerpts

Wednesday 2nd November 2011 Lords Chamber

[Lord Warner]

My Lords, as they say in commercial television, welcome back after the break. In moving Amendment 12, I shall speak also to Amendments 16, 17, 182, 183 and 184 tabled in my name and those of other noble Lords. I have also added my name to Amendment 18 to which my noble friend Lord Rooker will speak—I hope. The theme of these amendments is that of giving greater prominence in the Bill to the issue of service integration not just within NHS services, but across the health and social care boundary. At the same time, I will try to give some clearer meaning to this term by offering a definition in Amendment 184. This is a very complex issue and it has not been helped, if I may say so, in some of the public discourse by the way that the term “integration” has been used in a wide variety of ways by different people.

I shall start with some remarks about integration and its relationship to competition, which has been the subject of quite a lot of debate around this Bill and NHS reform. In recent months, the term “integration” has been bandied about as a kind of panacea for the NHS in the challenges it faces, but with little clarity about what it means. The Future Forum put the issue of integration on the map in its report. Some of this affection for integration has grown because it has been seen as a useful term by opponents of competition. They have tried to make the argument stand up that somehow if you have integration of services, you cannot support competition because the two are incompatible. I do not believe that to be true. It is perfectly possible to have the right kind of integration within a competitive market. Kaiser Permanente, among others, has shown this to be the case in the United States. Indeed, it was the very competitiveness of that market which caused Kaiser to offer patients more clinical integration in order to survive and flourish in the marketplace. That integration was done on the basis of reducing the use of in-patient hospital services. It is worth noting that there are NHS-Kaiser Permanente partnerships in six areas of the NHS which are adapting lessons from Kaiser’s experience in the US to apply in this country.

Having got that off my chest, I turn now to the issue of how integration and competition can coexist and how we need to be clear on what we are talking about when we use the term “integration”. There is, I suggest, good and less good integration. Much so-called organisational integration is effectively mergers of providers with little benefit to patients and often involving a reduction in choice. We see this in integration horizontally across organisations of the same kind and vertically between community and hospital services. The former is often done to save costs and reduce competition, while the latter is too often a way of securing patients for in-patient services and maintaining hospital income. Some will disagree with that, but it is certainly a perspective we should think about. Organisational integrations of this kind have sometimes fallen foul of the competition and collaboration panel. They are to be viewed with a sceptical eye, although I accept that integrated commissioning can be a major benefit for patients.

The integration, however, that is likely to benefit patients the most, and the cost structure of the NHS the greatest, is integration that brings together the assessment and delivery of health and social care services at the point of assessment and delivery to the individual person. This is the type of integration we have attempted to define in Amendment 184. At a time when such a large part of the NHS’s work involves patients with long-term conditions, who often require social care as well as healthcare, this is the type of integration that NHS and social care organisations and personnel should be focused on, particularly those commissioning services. These commissioners need to look for a new breed of service integrators who can take responsibility for integrating services for individuals across the health and social care boundary or divide, depending on your perspective. The Conservative’s community care reforms of 20 years ago produced care managers as integrators of social care in a mixed economy of providers. We now need to apply the same thinking to the whole spectrum of health and social care, especially for those with long-term conditions.

None of this will be easy, but if the NHS is to meet the financial and other challenges it faces and reduce its dependence on expensive, often unsustainable and often inappropriate, acute hospital services, it must begin the process of improving service integration at the level of the individual and not just the organisation. It is important that we use the Bill to set a new direction of travel on service integration for both the NHS and the social care worlds. The word “integration” needs to move from a term of rhetorical flourish to a reality that benefits people at the local level.

Of course, simply putting words in a Bill will not on its own change things; they will need to be backed up by changes in the professional culture, the use of IT and the financial reimbursement system. Later in the Bill I shall move amendments to help integration in the areas of tariffs and the use and extension of an electronic patient record. In the mean time, I want to establish a bridgehead in the Bill with this group of amendments that give more prominence to integration and try to define it. My co-signatories will expand on some of the arguments.

I should make it clear that I do not regard the wording of these amendments as the last word on the subject. I am sure they could be improved and they may have consequences for other parts of this leviathan of a Bill that we have failed to spot. I also recognise that the Labour Government had integrated care organisation pilots and that the Department of Health and the King’s Fund are working on the issue of integrated care following the Future Forum report. It is no purpose of these amendments to pre-empt or damage that work. I and my co-signatories are seeking to establish today whether the Minister is up for amending the Bill to give more prominence, more precision and greater reality to the term “integration” to shape the future commissioning and provision of services in ways that will benefit patients. We will be glad to sit down with him and his officials to improve the wording of the amendments and their placement in the Bill. I beg to move.

[Lord Patel]

I support the amendments to which my name is attached. This is an important issue. As the noble Lord, Lord Warner, mentioned, at some of the seminars we heard the word “integration” used in different forms with no clear definition of what it meant.

Future Forum, of course, put integrated care at the heart of NHS reform, but who will ensure that integrated care is not crowded out by the emphasis on competition and any qualified provider? What can clinical commissioning groups do to stimulate providers to work together to meet the needs of the patient?

As the noble Lord, Lord Warner, mentioned, integrated care takes many different forms and may involve whole populations; care for particular groups or people with the same diseases; and co-ordination of care for individual service users and carers.

There is good evidence of the benefits of integrated care for whole populations and for older people. There is mixed evidence of its benefits for people with long-term conditions such as diabetes and for people with complex needs. I will return to that later. Of course, Kaiser Permanente is one of the good examples of managing integrated care for long-term conditions but there are not that many.

The commissioning groups will need support from the NHS Commissioning Board as they set about commissioning integrated care. That includes advice on matters of contracting and procurement, outcomes and quality measures to include in contracts, and the tariffs and incentives to use. Work is also needed on how to create the right incentives to support integrated care. Payment by results was designed primarily to support choice and competition in relation to elective care. Alternative forms of payment are required to support integrated care, especially for people with chronic diseases and to support more co-ordinated, unplanned care when funding is tight. That will have to involve the providers.

Other factors that appear to support integrated care commissioning include robust performance management, sufficient time and resources from the provider side, and adequate investment in the main stages of the commissioning cycle, such as needs assessment, service design, contracting and tendering, and outcome-based evaluations. As management and resources shrink, there are obvious questions about whether clinical commissioners will have the necessary time and support to plan and contract for changed services in profound ways. To be more specific, there need to be resources at a national level to avoid commissioners at a local level reinventing the wheel many times over.

To turn briefly to long-term conditions, in the next decade the health and social care system will have to contend with an ageing population, increasing numbers of people with complex long-term conditions, budget constraints, increasingly sophisticated and expensive treatments, and rising expectations of what healthcare services should deliver. An integrated care approach to meeting these challenges—through better co-ordination of health and social care services, reducing the fragmentation or duplication of care—has the potential to improve support for the management of these complex needs.

Let me share a true story as an example of the issues here. Somebody approached me just before Second Reading of the health Bill. I mentioned this at one of the seminars and have since checked the authenticity, and visited the person in the hospital where care is currently provided. This person has insulin-dependent diabetes and was found to have an ulcer on the leg. He saw his GP who suggested that dressings would be required to try to heal the ulcer. During the process of that treatment, a specialist diabetic nurse who came in contact with the person suggested that they might be better getting advice from a specialist unit. While the GP suggested that the care provided was satisfactory, the person demanded to be referred to a hospital. By the time he got to the hospital, three of his toes were necrotic. They had to be removed last week. The patient needed an angiogram to decide whether the blood flow was satisfactory so as to put stents in so that he would not lose further parts of his limbs.

As we all know, it is crucial for diabetic patients to avoid certain complications. Good glycaemic control is required to manage that, so that their sight and renal functions do not deteriorate, their cardiovascular functions remain good and they also do not lose limbs because of necroticism. This shows the need for integrated care that requires the whole team to work together. For a start there need to be good records and IT that can transfer information between different carers, GPs, practice nurses, specialist nurses, and specialists in diabetes. There needs to be screening for eyes, kidneys, blood pressure, diet, cardiovascular disease and so on. Most importantly, there needs to be joint training for people who look after these patients, whether that is in the community or in specialist units.

If you are looking for good outcomes for patients, integrated care is what matters. It should be based on the journey of care—the patient pathway of care. That is what we need to establish. I hope, as the noble Lord, Lord Warner, said, that we can have further discussion to try to improve this Bill and see if we can deliver that.

Health and Social Care Bill

Lord Patel Excerpts

Tuesday 25th October 2011 Lords Chamber

Clause 1 : Secretary of State's duty to promote comprehensive health service

[Lord Patel]

My Lords, I shall just say something while I wait for my noble friend Lord Walton. My name is to Amendment 2, and I have no doubt that when my noble friend returns—I am glad to see that he has.

Amendment 2

Moved by

--- Later in debate ---

[Lord Patel]

My Lords, my name is added to this amendment along with that of the noble Lord, Lord Walton of Detchant. He has alluded to the need to include this amendment in the Bill. I consider that not only do we need it but that it is not strong enough. We may have to consider making it stronger. I say this because it is important to indicate on the face of the Bill that the Secretary of State has the responsibility to promote and secure a high-level of education in the whole of the workforce that delivers healthcare. I use the example of medical education and training but that applies equally to the training of nurses and other health professionals who are also regulated.

The current system of medical education and training—a model that is copied by many other countries and is widely respected—has evolved over many years. It is not something that was planned overnight and then executed. It has delivered well trained doctors who have improved healthcare. The system is complex and its essential relationships with different organisations and responsibilities are well documented. Only about 18 months ago, legislation was introduced which further changed the regulatory mechanisms for the training of doctors and nurses by making the General Medical Council the sole regulator of doctors’ training from entry to medical school to the day they retire, including postgraduate training, continuing professional development and revalidation. If we tinker with this, we run the risk of fragmenting it and making it inconsistent.

As my noble friend has already mentioned, under the GMC we have postgraduate deans, the royal colleges, the deaneries, undergraduate deaneries and the local hospitals where doctors are trained. These work together in a complex relationship to deliver high-quality medical education and training. The Department of Health has issued a consultation document, Liberating the NHS: Developing the Healthcare Workforce. Some of its proposals have caused a great deal of concern. If those proposals are implemented we run the risk of damaging what has been built up over many years. Adopting a localised approach to education, training and workforce planning to meet the short-term needs of employers will destroy the national training for a national workforce that has been developed over a long time.

There are many other concerns; for instance, the lack of clarity over the role of Health Education England. How will it hold education providers and commissioners to account? There are serious concerns about the continuing role of postgraduate deans, a very important group of people in the delivery and quality assurance of medical education and training. Uncertainties about the role of postgraduate deans are already leading to concerns about managing the recruitment of doctors into training in 2012. There is a lack of information about what part local skills networks will play and about the risk of serious damage occurring to workforce planning, and a lack of clarity about their governance and accountability. The training of doctors also includes training in research methodologies, as the noble Lord, Lord Walton, mentioned. Development of academic doctors is crucial. We already have a problem with recruitment to academic medicine. Therefore, training in research methodologies, postgraduate research and higher degrees in research is crucial. None of these is included in the Bill. They are not included because, we are told, there will be a second Bill. It might even be called the social care and health Bill as opposed to the Health and Social Care Bill. However, we are waiting for the responses from Future Forum, which is considering this. Then we will have the Government’s response, despite the fact that they have indicated that all the proposals in Liberating the NHS: Developing the Healthcare Workforce will need to be implemented by April 2012—the time is rather short. Perhaps the Minister will indicate when we are likely to see this Bill related to education and training. If there is not a satisfactory answer, we may have to consider putting a framework for medical education and training in this Bill.

[Baroness Finlay of Llandaff]

My Lords, I have two amendments in this group, but noble Lords who have looked at them will have noticed that they are almost identical. One of them has inverted commas in it. At this point, I ask the Committee to discount Amendment 8B because the inverted commas do not mean a great deal. However, I would like to take a moment out to pay tribute to those in the Public Bill Office, where this drafting error occurred, and I know exactly why. They have had unending patience, have been infinitely polite to everybody who has gone up there and have provided impartial advice when under enormous pressure. So if this is the only mistake they have made with my amendments, they have done amazingly well.

I would now like to quote from the report from Future Forum by Steve Field. In it he pointed out:

“The professional development of all staff providing NHS funded services is critical to the delivery of safe, high-quality care but is not being taken seriously enough”.

I am glad to see that the Government have also decided to put down an amendment providing that we should state on the face of this Bill the importance of education and training.

Amendment 8A is almost exactly the same as Amendment 6 except that it adds the words, “a nationally co-ordinated system”. The reason is that currently, the standards are set by deaneries, the royal colleges, the universities and the regulators. At the other end from the high-profile degrees and specialist competencies from the royal colleges, there are qualifications such as the NVQs, which have been used for training healthcare assistants. There has recently been much debate about the standard of healthcare assistants, but I think there is a foundation there that could be built on to raise standards across the board. However, it needs to be nationally co-ordinated rather than have lots of odd little bits of training in one particular area, because otherwise when staff transfer, the organisation of management of another area believes that they are adequately trained, when actually there is no national benchmark for that competency. That is why I put in the words “nationally co-ordinated”.

I turn to the amendment put down by the Government. I hope that the Minister will explain how those deaneries and those national co-ordinating bodies that set standards will link in. Will the national Commissioning Board and the clinical commissioning groups have to consider education and training in everything that they do? If they do, the deaneries will have a national planning function in conjunction with the royal colleges and specialist societies which set specific competency standards. I also wonder whether this government amendment, which talks about the health service in England, takes consideration of the NHS in Wales and Northern Ireland. If it does, how would that happen and, if it does not, what arrangements have been made with the devolved Administrations?

I should also ask whether the Secretary of State has a comprehensive duty. Will the national Commissioning Board and clinical commissioning groups have a duty to include education and training when deciding contracts and making commissioning decisions? If they do not do build in education and training right across the piece, will an appeal go to the Secretary of State?

In proposed new subsection (1) of the Government’s amendment, there is mention of,

“provision of services as part of the health service”.

Given the nature of the health service as we see it developing, am I right to understand that that would include all private providers, all voluntary sector providers and all public health and health protection arrangements? Am I right that any provider which does not then provide education and training would need to prove why they were exempt from providing it, if they have a contract for a specific service?

We heard earlier about the independent treatment centres and the sense that they had milked off some healthcare services but had not undertaken training and education. We hear now about specialist trainees in some of the disciplines. Orthopaedics is a clear example whereby a lot of shoulder and knee surgery is not being done in their training environment, so the trainees are not adequately exposed to the range of operations. Indeed, an orthopaedic surgeon contacted me about how she was crowded out in theatre by trainees desperate to watch her carry out a shoulder operation simply because they had not seen that operation done—whereas previously they had broader experience.

If the clinical care of patients is contracted out to private sector or voluntary sector providers, the clinical experience associated with providing that care, if it is high quality, will provide a fantastic education and training opportunity. If we are truly developing a healthcare workforce that will be comprehensive for the needs of the nation, it does not matter who owns the building or the service where that patient is being treated. If that is really high quality, there is much to be learnt. In all the years when I have asked patients if they minded students, postgraduates or whoever being present, there have been only two occasions when patients have said that they would prefer them not to be there—and they were for very understandable reasons. Everyone understands the need to educate and train, and the majority of patients understand that if the person looking after them is also teaching they are being held to account by the group that they are teaching.

Those are some of my questions to the Minister when he comes to speak to his amendment. I ask the noble Baroness, Lady Thornton, and the noble Lord, Lord Hunt of Kings Heath, whether they see the use of the word “comprehensive” as a duty on the national Commissioning Board and clinical commissioning groups, and whether, when they talk about delivering NHS services, they are intending that private providers and public health are included.

My final point is: whichever of these amendments is agreed—and I have a sneaking suspicion that mine will not be top of the polls; but that is the way it tumbles—the different providers, whoever they are, need to contribute to the cost of education and training. I suggest that when determining a tariff, those who do not contribute to education and training on a particular part that they are providing should not receive the full tariff because they will be ducking out of part of the ongoing responsibility to secure the nation’s health.

--- Later in debate ---

[Earl Howe]

The trouble with that is that we are straying into the mechanics and the detail of the education and training system, and we are still consulting on how it will work. That is the difficulty I have in answering some of the detailed questions that are being put to me. I can answer many of them, but once we move into particular questions on how the system for education and training will all fit together, it would be imprudent of me to put anything on to the record at this stage.

[Lord Patel]

I go back to the question that the noble Lord, Lord Warner, asked. In the event that the example he gave should happen, ipso facto, it would mean that Health Education England had failed.

[Earl Howe]

It might or it might not. All I can say is that the Department of Health will have designed and co-ordinated the new system and will develop the outcomes framework. Health Education England will be providing oversight and national leadership for education and training. The department and Health Education England, together, would no doubt have a role in sorting out the kind of situation that the noble Lord, Lord Warner, has adumbrated. However, it is a little difficult to discuss this in hypothetical terms. I have tried to set out, broadly, how the system should operate—

--- Later in debate ---

[Earl Howe]

As I read it, it is the noble Lord’s amendment and it is for him to speak to it, but it refers to the education and training of “the health care workforce”. That will include a lot of people, but not those who are not healthcare workers.

[Lord Patel]

That depends on the interpretation of the word “care”.

[Lord Walton of Detchant]

My Lords, this has been a lengthy debate on an extremely complex and difficult matter in a complex and detailed Bill. Medical education and training of the entire NHS workforce is absolutely crucial and it is vital that it appears in this Bill. That is why I very much hope that the Minister will take away Amendment 2 and think about trying to persuade the Government to adopt it. Other issues that have been raised will not go away. For instance, my medical colleague, the noble Lord, Lord Alderdice, talked about psychotherapists. There was also talk about the crucial problem of the future of healthcare assistants.

I would remind your Lordships that 15 years ago I steered through this House the Bills to regulate chiropractors, followed by regulation of osteopaths, so that they are now regulated by statute. I also chaired the House of Lords Select Committee on complementary and alternative medicine, which held a detailed inquiry. In that field, too, it is good to know that herbal medicine practitioners are close to being regulated. Therefore people who work in other aspects of healthcare will have to consider whether or not they will need and require statutory registration and regulation, though not in this Bill perhaps.

The government amendment is right as far as it goes, but it leaves a massive amount of information still up in the air. The Minister has given us a comprehensive and detailed report about the future of Health Education England. There is already a body called Health Education England, which has been in existence for some little time. I do not know what its provenance is now, but it is chaired by my close friend, Sir Christopher Edwards, who is a former vice-chancellor of the University of Newcastle upon Tyne. He has chaired a body called Health Education England for a while.

[Lord Patel]

It is Medical Education England.

[Lord Walton of Detchant]

Medical Education England, I beg your pardon. Will that body disappear with the development of Health Education England? Do we know what the provenance of that body is going to be or who is going to fund it? What is its constitution going to be and what are its authorities? Will it have the authority to deal with the issues that we raised in this debate about the crucial importance of making certain that commissioning groups, trusts and even private providers offer facilities for education and training.

I shall not go on. I am happy now to withdraw the amendment in my name, but I believe that these issues are so important that they should not await the tabling of another government Bill on education. The Government should introduce something into this Bill to make the future of health education and training clear. I beg leave to withdraw Amendment 2.

Health and Social Care Bill

Lord Patel Excerpts

Wednesday 12th October 2011 Lords Chamber

[Lord Patel]

My Lords, I declare an interest in that I hold fellowships of several colleges. As I am going to speak about medical research, I should also say that I am a member of the Medical Research Council and a fellow of the Academy of Medical Sciences—all of which is probably quite irrelevant to what I am going to say.

I agree with my noble friend Lord Winston that much of this Bill is probably unnecessary. However, we have the Bill, and I will try to focus on issues related to it. I thank the noble Earl, Lord Howe, not only for the way in which he introduced the Bill but also for making time on several occasions to meet me to discuss issues that concern me. I am also slightly concerned at the number of hours he has been sitting in his place. I hope that he is doing sitting exercises to avoid deep vein thrombosis.

The Secretary of State, in his keynote speech at the Conservative Party conference, said: “On my watch, the NHS will not be privatised, fragmented or dismantled”. Judging by the huge amount of briefs, mail and e-mails that we have all had, the perception of those who work in the NHS, patients and the public is the reverse. If the reforms are to work, listening to those who work in the NHS and to patients is going to be important.

Advances in diagnosis and treatments in areas such as cell therapy, genomics medicine, molecular diagnostics, regenerative medicine, nano-medicine and focused ultrasound therapy—to mention but a few—will be available probably in the next 10 years. It will be expensive, but it will also require a reconfiguration of health services to take advantage of it as well as better evaluation of the effectiveness of treatments. In some parts of the country patients are already not benefiting from the latest diagnostics and treatment, particularly those relating to cancer. To contain costs, better strategies for public health will be required, including regulation of diabetogenic products marketed in the high streets. The burden of lifestyle and environment-related diseases is huge and increasing: it accounts for nearly 40 per cent of in-patient admissions.

We also need more effective management of patients with long-term conditions, ideally in the community, delivered in an appropriate environment by skilled healthcare professionals. These patients are vulnerable and their experience of healthcare is often variable. I agree with the noble Lord, Lord Crisp, that we have lost an opportunity in this Bill by not having developed a strategy for delivery of treatment for patients with long-term conditions.

I agree that we need change. But is the scale of reforms proportionate, appropriate and timely? Will the many layers of increased administration that the Minister referred to lead to confusion, bureaucracy and increased costs? Some estimates suggest that there may well be between 25,000 and 30,000 people employed in the NHS Commissioning Board, the CQC, Monitor and the 350-odd clinical commissioning groups, none of whom will be involved in the direct provision of patient care. The NHS Commissioning Board alone may have upwards of 5,000 employees.

I turn now to some of the points raised by other noble Lords whose comments I support. Yesterday’s best advice to the noble Earl, as it was put, came from the noble Lord, Lord Willis of Knaresborough. Later I shall have another piece of best advice for today. However, the noble Lord, Lord Willis, was right to say that establishing the health research authority is crucial. I also hope that the Bill will provide stronger support for a duty on all healthcare providers to be involved in promoting clinical research. I will therefore support the amendments tabled by the noble Lord, Lord Willis.

My noble friend Lord Walton of Detchant expressed strongly the need for the UK to be recognised internationally for good medical training. The Bill’s proposals on the role of health education in England and of the regulator of medical education and training, the General Medical Council, cause confusion. Nothing should be done to change national training programmes. I hope that my noble friend Lord Walton will bring forward amendments that others will be able to support.

Equally, the noble Baroness, Lady Emerton, referred to several important issues relating to the training of nurses, nurse support workers, the representation of nurses on national bodies and safe staffing ratios. I will support her amendments. As a clinician, I understand very clearly that good nursing care makes patients better. She also mentioned Cause 231, but I am sure that she meant Clauses 225 and 226.

The strategy for delivering the public health agenda needs to be strengthened. There is a risk that, as currently drafted, the structures will not deliver the improvements that we need. There is also an issue about the public health workforce. I hope to have amendments on that which I hope will be accepted as a way of improving the delivery of the public health agenda.

The Minister referred to public and patient involvement. If the Government are serious, HealthWatch England should be given a stronger voice. It should be an independent body and not a committee of the CQC; it should be represented on the boards of the NHS Commissioning Board, Monitor and the CQC; and it should be well resourced. That is today’s best advice. I will table an amendment to propose that and I hope that the Minister will accept it.

The noble Earl’s key ministerial responsibility is for quality in healthcare, which is defined as effectiveness, patient safety and patient experience. The quality standards developed by NICE will be the key drivers of quality in the NHS. To be effective, they need to be based on the patient’s journey of care, as I learned when developing quality standards myself. The noble Baroness, Lady Jay of Paddington, is not in her place so I will save her blushes. I wrote her a letter on 16 October 1997 and enclosed a paper on behalf of the Academy of Medical Royal Colleges, of which I was then the chair. The purpose of the paper was to establish a three-pronged approach to improving quality of care through the use of quality clinical indicators; a strategy for developing clinical effectiveness and the accreditation of clinical services licensing through peer review; and, to do this, to establish a body called the national institute of clinical effectiveness. I am glad that it survives as NICE.

The quality standards developed by NICE will be the key drivers of quality in the NHS. They need to reflect the patient’s journey of care and to be used by the national Commissioning Board to develop currency—currency which will be used by Monitor to develop tariffs. The tariffs need to be bundled to deliver effective, integrated care that will result in good outcomes. The pricing has to be appropriate, and therefore should be reflected in the tariffs that the commissioners will use to purchase care.

However, I have to ask why there is such a convoluted way of developing tariffs. Why is there the involvement of the national Commissioning Board, Monitor and the commissioners? The NICE quality standards used by the commission could be simplified, and social care could be included.

The quality regulator, the CQC, will be responsible for making sure that the providers of healthcare follow the quality standards, but the methodology will need to be refined. The best way of assessing healthcare and monitoring quality is through peer review, as experience in other countries such as the United States has shown—and in England we also have the example of cardiac and thoracic surgery. The 300 to 350 clinical commissioning groups will use tariffs to purchase care. Good commissioning has been patchy. The Bill is unclear how that will be developed. How will conflict of interest by primary care doctors, as providers of care, and members of the commissioning group be managed? I have an issue with quality premiums—what they will be used for and the criteria for awarding them.

Performance management of GPs as providers of care is also not clear. When will we have a primary care outcomes framework? I hope that GP referral rates will not be used as indicators for quality payments. We already have evidence that for many patients, particularly cancer patients, late referrals produce poor outcomes. The noble Baroness, Lady Royall of Blaisdon, spoke yesterday—movingly and courageously—about her own family experience.

I think that Monitor as a sector regulator has too many tasks that it need not have. However, one task that it should have is as a financial regulator of social care. Healthcare regulation is complicated; it is not comparable to utilities regulation. Evidence presented at a recent seminar showed that successful regulators are simple regulators.

Time does not allow me to comment on other important issues related to competition, choice, integration, the failure regime and reconfiguration, which are important issues. Some of them have already been mentioned by the noble Lord, Lord Warner, who I hope to join with in the amendments that he brings forward. No doubt we shall have an opportunity to discuss this in detail later.

As many noble Lords have commented, this is a complex and large Bill. I hope that the business managers will recognise the need to allow appropriate time for the Committee stage. In common with other noble Lords, my intention is to improve the Bill, make the delivery of healthcare in the NHS better, and build on what is already good.

Health: Breast Cancer

Lord Patel Excerpts

Monday 3rd October 2011 Lords Chamber

[Earl Howe]

My Lords, there are broadly three ways in which we can attain that target. The main way is through early diagnosis—in particular, by making sure that women are aware of the signs and symptoms that could indicate breast cancer—but also by improving access to screening and to radiotherapy, which has already been covered in the question from the noble Baroness, Lady Morgan. To support the NHS to achieve earlier diagnosis of cancer, the strategy has been backed by over £450 million over the next four years. That is part of over £750 million additional funding for cancer over the spending review period.

[Lord Patel]

My Lords, we know that one of the reasons for the poor outcomes on cancers is the late referrals of patients who suffer from cancers. We are now likely to have performance management of primary care doctors being based on their referral patterns. Can the Minister confirm that there will be no financial incentive for reducing referrals of suspected cancer patients for treatment?

[Earl Howe]

Yes, I can, my Lords. It is very important that doctors should feel absolutely free to refer patients. I remind the noble Lord that it is a right for patients, under the NHS constitution, to expect to be referred within the laid-down waiting time maximum periods, so we are very clear that there should be nothing to interfere with doctors’ clinical judgment in this area.

NHS: Cost-effectiveness

Lord Patel Excerpts

Monday 12th September 2011 Lords Chamber

[Earl Howe]

I commend to the noble Baroness the impact assessment that we published on the Bill. It shows clearly that, over the next 10 years, the savings that we will bring about will dwarf the cost of making the changes that we propose.

[Lord Patel]

Does the Minister agree that improving the quality of healthcare will lead to higher costs?

[Earl Howe]

No, I do not. There are plenty of examples of quality costing less because the system gets it right first time. We see this time and again, for example in the Quit programme. The simplest example is that if we can treat patients correctly in hospital and keep them in for the shortest amount of time, we save a great deal of money.

NHS: Hospitals

Lord Patel Excerpts

Thursday 8th September 2011 Lords Chamber

[Earl Howe]

My Lords, I am grateful to my noble friend for that question. I am sorry to say that I do not have those figures in front of me, but she is absolutely right to make the point that the independent sector treatment centres introduced by the previous Government were a perfectly proper move to increase choice for patients, and in many cases we have seen the quality of care in those hospitals encourage the NHS to raise its own game. Competition on that basis is highly beneficial.

[Lord Patel]

Will the Minister say what assessment has been made of the causes of low productivity in the NHS?

[Earl Howe]

My Lords, it is clear that one of the causes was that the previous Government—for all the right reasons, I have to say—injected very large sums of additional money into the health service, but alongside that there was no commensurate increase in activity. A lot of the additional money went into settling pay claims. That is not to decry the many benefits that arose from the additional money, but the net effect was a decline in productivity.

NHS: Medical Records

Lord Patel Excerpts

Wednesday 7th September 2011 Lords Chamber

[Earl Howe]

I pay tribute to the work that the noble Lord did when he was a Minister. Yes, the Government are committed to a summary care record, which, for the benefit of noble Lords, is a record that includes a defined set of key patient data, other than for patients who choose to opt out—that is an important rider. Clinicians can then access essential medical information that they need to support safe treatment and to reduce the risk of inadvertent harm, especially during emergency care. To answer the second question that the noble Lord asked, over six million patients now have a summary care record, which is a considerable increase over a few months ago.

[Lord Patel]

My Lords, would the Minister agree that to improve the quality of healthcare we would need comparable indicators of health outcomes? In the absence of nationally collected computerised data, how would we achieve this?

[Earl Howe]

My Lords, the noble Lord is absolutely right. We have to measure performance in order to improve upon it. That is why we are focused on producing an information strategy, which we hope to publish later this year. A lot of work has already gone on and the NHS Future Forum, as he may know, is looking at this area. He is absolutely right that this will be central to the performance management of the NHS.