Nursing

Lord Ribeiro Excerpts

Thursday 1st December 2011 Lords Chamber

[Lord Ribeiro]

My Lords, I apologise for speaking in the gap without giving notice, but I could not let the noble Lord, Lord Patel, give the impression that he was the only doctor here who was prepared to speak. I thought that I would share some thoughts on my view of nursing, which I have to limit to my own special interests of surgery as they are the only group of nurses I know anything about.

It is interesting that reference was made to the Salmon report, which I think was produced in 1968 when I was a fairly young junior doctor in the Middlesex hospital, which sadly no longer exits. We had a matron, wing sisters and ward sisters, and there was no question about who was in charge. There was leadership right down to the ward level, and the important thing about nurses at that time—there are still quite a few of them out there today—was that they knew they were in charge. They had responsibility for the ward and I totally agree that we should not wait for the hospital manager to say that a sister of a ward cannot tell the cleaning staff that they have to stop. I well remember doing ward rounds at Basildon hospital when the sister would put a notice on the door saying, “Ward round in progress. Consultant present. Quiet please”. If the cleaning staff tried to come in she would tell them to go away until the ward round was finished. Latterly we would not dare tell the cleaning staff to go away because their response would be, “If I don’t clean this ward now I’m not coming back”. There has to be proper leadership. It does not have to come from Richmond House; it has to come from within the organisation, seeing its responsibility to ensure that leadership is delivered. Leadership is the key—knowing who is in charge.

One of the things that has been said about doctors is that they have treated nurses as their handmaidens. It may be said that doctors have been resistant to seeing nurses progress, and we have had a long debate about training, education and diplomas, which I shall not go into. But the opportunities that opened up for nurses after Salmon did provide nurses with a way to move into management and other areas. The advantage for nurses is that their opinion and advice has influenced medical care over the past 40 years that I have been in medicine, and much of it to the good. The downside has been that we have created another pathway for nurses to go other than the ward. Therefore, talented nurses may have wanted to stay on the ward but if they wished to progress and improve their salary status, they had to go sideways into management. That is where some of the problem has emanated from. We must look at ways of remunerating and keeping nurses who want to stay on the wards to do so.

I shall not speak for long but I want also to make a point about teamwork—nurses and their contribution to the team function. As a surgeon, like the noble Lord, Lord Patel, I know that we work in a close team. Our main team is the ward staff and ward sister who look after our patients. In my case the ward sister would tell me through the grapevine when my junior doctors were not doing all that they should. There is a big function for the ward sister, other than just looking after patients. In theatre, you have a close-knit team. Another thing that I regret is that in the old days many nurses would come along and observe what was going on in theatre and say that they would like to become theatre sisters. They were encouraged to go into it. Latterly in my time as a consultant, I found that fewer and fewer nurses were being directed to go to work in theatre. I think this is a great shame because we live in a world of multidisciplinary working, and it is important that nurses should be encouraged to specialise if they wish to.

Finally, I came back from Afghanistan recently, and in answer to the noble Baroness, Lady Masham, I have to say that the nursing teams in Camp Bastian are superb. Many of them are volunteers from this country, and their contribution to the war effort in Afghanistan has to be noted and applauded.

Health and Social Care Bill

Lord Ribeiro Excerpts

Tuesday 22nd November 2011 Lords Chamber

[Lord Ribeiro]

My Lords, I thank the noble Baroness, Lady Thornton, for her comments about integration, because I agree with her that we do not have a clear definition. On page 18 of the Bill, new Section 13M is headed:

“Duty as to promoting integration”.

Although the words “integration” and “integrated” are used in the section, there is no clear definition. Yet, in new subsection 4, there is an attempt to define “health-related services” and “social care services”, but not until new Section 13Z3 is there an interpretation which tries to define the “health service” and “health services”. We do need some clear definition of what we mean by integration. Let me tell you what I thought integration meant, when I first took on an interest in the Bill, and I will illustrate it with some examples.

Integration, for me, was not being able to talk to my GP colleague about a patient without having to go through the PCT. I could not just pick up the telephone and say, “I’ll see your patient next Friday”. It had to go through a bureaucratic system before the patient got to me.

From a clinical point of view, when I was referred a patient with gallstones on a Monday morning clinic, after discussing and examining the patient, confirming that she did indeed have gallstones—and I used to have an ultrasound machine in my out-patient clinic, so it was easy to make the diagnosis—I said to her, “I think we can deal with this quite easily with a keyhole operation to remove your gallbladder, but I suspect you may also have an ulcer in your stomach, so before I put you on the list for surgery, it might be a good idea to exclude that”. I went down the corridor to see my gastroenterology colleague, told him about the problem, and he said, “Not an issue, bring her along, and I’ll see her”. Before I knew it, I had had a phone call saying, “I will deal with her next Thursday and gastroscope her”.

The net result of that was that within a week we had an answer for the lady, and I was able to put her on the waiting list for surgery. However, when choice and tariffs came in, it was essential, for the hospital to be paid, that when the patient came to see me in the outpatients’ clinic and was diagnosed with gallstones, I would have to refer her back to her GP, who would then make another consultation with the clinician gastroenterologist in order for her to have the endoscopy to diagnose her ulcer. Those were two inconvenient visits for that patient, purely to fulfil the need to manage the tariff and the issues around choice.

For me, an integrated service gets rid of all those barriers. We should also remember that this is the Health and Social Care Bill; it is about integrating services from the beginning to the end. I have tremendous sympathy and support for Amendments 103 and 290, from the noble Lord, Lord Warner, because they are about getting rid of episodic care. It was precisely the episodic tariffs that required my patient to make two visits to the hospital when one would have done. I hope the Minister will take this into consideration when reviewing this. It is important that we find a formula, or a way to look at the care pathway, and find a way to cost that, rather than the episodic costing of care.

[Lord Turnberg]

My Lords, I will speak to Amendments 103, 104A, 106, 135A, and several of the others in this group. Clause 20, new Section 13M, highlights integration of services as something the Commissioning Board should “exercise its functions” to secure,

“where it considers that this would—

(a) improve the quality of those services”.

That is all well and good, but by itself it seems insufficient. Integration is of course difficult to pin down. We have heard quite a bit about that this evening, and I will not repeat those remarks. I know what I mean by integration, so I will give you my particular understanding, for the purposes I want to talk about, using the term to mean a seamless service for those patients, usually elderly and with multiple diseases, who need both hospital and community care, and flit between the two.

It is unfortunately the case that the integration that is needed between health and social services has seen so many failures and been so elusive, despite many wasted words. We have an opportunity here to correct these failures, so I was somewhat disappointed when the Minister said in the debate on 2 November, when we were discussing the role of the Secretary of State, that the Government were,

“not in the business of dictating the processes”—

and that—

“integration is neither a necessary nor a sufficient condition of a good outcome”.—[Official Report, 2/11/11; col. 1334.]

Surely if integrated care is a good thing—and I think few will deny that—then we must give a lead on how it might be achieved. We cannot ignore the process, and must at least try to see what conditions are necessary for successful integration. We should not go around simply saying it is a good thing, without showing how it might be achieved.

There are many examples out there that we can build upon. We are not entirely in uncharted territory. The noble Baroness, Lady Cumberlege, mentioned Assura Cambridge and services in Torbay in our last debate, and other noble Lords spoke of Kaiser Permanente, Northern Ireland, personal health budgets and information sharing, as valuable means to an end.

We also have the excellent report from the Nuffield Trust, Integration in Action, that analyses successful integration being carried out in four places across the world, including in Scotland. We are not working in a vacuum, and we could and should take advantage of all this information, and incorporate some of those ideas in the Bill without waiting for yet further work.

Of course, not everything can or should be put in the Bill, but we should see where we can strengthen it, by including more pointers to how we can improve the present, very unsatisfactory, position. Let me give some examples, leaning heavily on the Nuffield Trust report. First, the Commissioning Board should point the way by developing commissioning for bundled payments, and local tariffs for key conditions. I think that is possible. At the moment, fees for service for episodes of hospital care, as we have heard, work against integration with community service. That is something that the board should seek to redress quickly.

Secondly, we should design the national tariffs that we have heard about, which incorporate a full care pathway across the health and social service divide. Monitor and the board should work together to develop a pricing strategy that provides the incentives for integration. They should also develop ideas about how outcome measures, which are admittedly difficult to quantify when we are talking about a complex system like integrated care between hospital and social care, can be used to promote integration across the whole pathway of care. Contracts based on those measures can encourage providers to respond to the need to integrate. There is nothing here that obviates competition between providers, which I am sure will please my noble friend Lord Warner.

We will come later in the Bill to Monitor, but it too should link improvements in outcomes, including the patient’s experience, to the way it regulates integration. Then, there are several measures that clinical commissioning groups and local authorities should be encouraged to develop by the Commissioning Board. One huge area is of the improvements we desperately need in the flow of information between hospitals and community. Too often we rely on phone calls on the day of discharge, which is inefficient and fails most of the time. We should have an IT system which allows information to be shared across the divide. It only requires a competent programmer to produce the programme, and a safe system for preserving patient confidentiality and data protection. I am sure that that is not beyond our capacity.

There is also the need for joint funding and integrated governance arrangements, which we have had some discussion about. This is much easier said than done, but it can be done. We have seen it in action here and there and we must spread the good practice.

There is also the need for people to make the whole thing work on the ground: for example, liaison officers whose sole responsibility is to ensure that patients pass seamlessly across the divide, and nurses and doctors who move without constraint from one sphere to another. The example of specialist district nurses is a good one. They follow patients from hospital to the community and back, and are very much appreciated. Unfortunately, they are a threatened species and are disappearing, largely because neither the NHS nor local authorities will fund them. We must get around that problem.

Of course, much of what is needed depends on a change in the mindset of those working at the coalface in hospitals and the community. If through the Bill we can change the conditions from those that inhibit collaboration to those that encourage it, we can begin the process. The amendments bring a greater sense of the need to focus more strongly and urgently on the duties and responsibilities of the board in putting integration more firmly on the map as a way of improving outcomes. I support them strongly.

Health and Social Care Bill

Lord Ribeiro Excerpts

Monday 14th November 2011 Lords Chamber

Health Education England, when established, can audit the local education and training boards and maintain a national perspective. There is worrying information about the way things are going. I have spoken to the Medical Schools Council, which recently surveyed medical school involvement in the development of the emerging local education and training boards. It indicates a variable extent to which higher educational institutions are involved in planning and suggests that the structures will vary widely. In some areas, such as the north-west and the east Midlands, medical schools and higher educational institutes appear to be actively excluded from the developing local education and training boards. This is extremely worrying because in service transformation there needs to be quality control and academic rigour. Medical schools are required by the General Medical Council to act as quality managers of clinical placements but, by excluding those which are providing education from the local education and training boards, we risk having a serious disconnect in the way that services develop and are delivered, and in the way that our workforce is trained.

[Lord Ribeiro]

I have listened to the debate with considerable interest, particularly as it brings to our attention the whole concept of Health Education England. I think Health Education England is a work in progress, and the reason I say that is that, as a result of the MMC/MTAS debacle that took place in 2006-07, one of the major recommendations of the inquiry that followed by Sir John Tooke was that a new body should be set up called Medical Education England. That recommendation was accepted by the Government at the time, and by the Opposition. It started work under the chairmanship of Dr Patricia Hamilton, who has come to this House to give her views on the development of education and training.

The reason I mention that is that Medical Education England was designed to deal with medicine. Yet, as the noble Baroness, Lady Emerton, has said, more than 50 per cent of the multiprofessional education budget actually goes on nurses and other non-medical members. Therefore, it is totally inappropriate to be moving on to a Medical Education England model when clearly we have to encompass all the other health providers, and hence we have Health Education England. I understand the desire of the noble Lord, Lord Warner, to get on with this but, to get this to work, it needs to be thought through very carefully. One of the reasons—certainly from the medical point of view—is that, among the questions we asked in 2006 was, “What is the end point of training? What are we training these doctors for?”. One has always assumed that most medical treatments will occur within the hospital sector but we know, because of the ageing population, that more and more is being done in general practice and in the community. We therefore need to think very carefully about how we train doctors for the future and where they are going to work.

It is important, therefore, that we give time for the development of the workforce as well as the training and the education of the workforce. The noble Baroness, Lady Finlay of Llandaff, referred to the Centre for Workforce Intelligence, which is very important, but that is a new agency. I was in America last year, when a representative from it came to brief the American College of Surgeons Health Policy Research Institute on how it was trying to work out where doctors should go within the UK with respect to geography as well as specialty. They were taking advice from the Americans as to how they were trying to map and plan their health workforce.

I think this is work in progress. I welcome that this is a probing amendment, but I do not feel that at present we are in a position to roll out Health Education England without having heard the full report from the Future Forum.

[Lord Owen]

My Lords, I reiterate some of the comments that have already been made by many noble Lords on the sense of urgency about this issue. Above all, I feel rather like the man in the Bateman cartoon who mentions the words “party politics” in the Health and Social Care Bill in the House of Lords. There is here a very deep question. It is frankly inconceivable that there will be legislation in the next Session; I would think it would be almost inconceivable that there would be legislation on this before the next election, which is currently scheduled for 2015. Politicians simply do not usually go in for a repeat hiding, and this Bill has already had one hell of a political controversy. If we have legislation, it may be all on medical education, but it opens up a whole realm of party politics, which I just do not see being done.

Therefore, I want to make a practical suggestion to the Minister. There is a way through this if there could be bipartisan agreement. One only has to think of a situation in which there is no legislation until 2016 to realise that we are facing a real chasm in medical education and continuity. As I understand the legislation, the Secretary of State is empowered to create special health authorities. Whether he does that or removes the ones that are necessary, that power is there. If not, he could easily take it in the Bill.

There is so much cross-party agreement that doing something about health education is pretty urgent. I would have thought that it would be perfectly possible to meet most of the demands. The noble Lord, Lord Ribeiro, is completely right. We are not in a position to legislate now on anything other than a structure. That structure might be a temporary special health authority. It is not worth prejudging the question but, if it was a special health authority, it would need some form of regulation passed. As long as an agreement could be made—first on the clause that would be in the Bill, along the lines more of Amendment 47B than 47A; and, secondly, with the main substantive regulations for the special health authority done through an affirmative resolution—then it would be perfectly possible for us to move on the creation of this training authority, which has to embrace all the health professions and be pretty wide-ranging, some time at the end of 2012 or early 2013. That would meet the wishes of most people in the National Health Service.

It is really not enough to rest on the fact that there will be a Bill in the next Session of Parliament. I have already tried to convince my own college, the Royal College of Physicians, that it is highly unlikely that this will be fulfilled. As practical politicians, we should ask the Minister to take this away with a measure of real good will to see if there is some way through this issue which does not prejudice the long-term future but allows us to fill a very serious gap.

Health and Social Care Bill

Lord Ribeiro Excerpts

Wednesday 9th November 2011 Lords Chamber

[Lord Turnberg]

My Lords, I rise to speak to Amendments 40A and 199ZA in my name. I also want to comment on some other amendments in this group. I speak as a one-time medical researcher, a trustee of a number of medical research charities, and as a scientific adviser to the Association of Medical Research Charities. In that I work closely with my friend, the noble Lord, Lord Willis.

Research, as we have heard, is not an optional extra. It cannot be added on to the NHS as and when someone thinks it is needed; it is a vital and integral part and it is good to see an acknowledgement of that in the Bill, even if it falls a little short of full endorsement. Research is no cottage industry, with more than £1 billion coming from the research charities every year and almost the same amount going in from each of the Medical Research Council and the NIHR. That is a total of around £3 billion a year. As for the Department of Health’s contribution of almost £1 billion, I want to say how much Dame Sally Davies's role in securing that is appreciated, as indeed is that of the noble Earl who has been a great ally. However, Amendment 42 raises the question of whether this funding is secure for the future.

I can only re-emphasise what the noble Lords, Lord Willis and Lord Warner, have said. Even though research funding amounts to less than 1 per cent of the NHS budget—a pitifully small proportion in an organisation of this size—can we be reassured that it will not fall easy victim to the cuts we are going to see over the next few years? Is it really essential for this to be distributed through the Commissioning Board? Is it possible that it could come more directly via the Department of Health? I hope that the noble Earl will give us some comfort on this amendment. This is clearly of some importance and we almost certainly will have to come back to it at a later stage.

As we have heard, medical research in the United Kingdom punches way above its weight. By any measure, our outputs of research findings come high in any international league table and the fruits of our research are having a major impact on our health. We are living longer and healthier lives and one has only to look around your Lordships’ House to see evidence of that. I suspect that there are few of us who are not taking one or more pills, keeping us in fine fettle. As the noble Lord, Lord Willis, said, the public at large is well aware of the benefits. According to a number of surveys, more than 90 per cent of patients and the public want us to do this research and, furthermore, want to be engaged in it as patients. They want this even if it does not benefit them directly but benefits only future generations. However, they also know that any patient who is part of a trial incidentally gets a better deal and better care as part of the research process.

They are enthusiastic supporters but that is not the only reason why we should be supporting research. There are considerable economic benefits too. The most recent of several studies that have shown this, Medical Research: What's it Worth? supported by the Rand Foundation and the Wellcome Trust, clearly showed that we gain between 35 and 40 per cent return per annum for every pound we put in. Although it takes several years for research done now to bear fruit—today it is coming from research done some years ago—the returns come from less sickness and absenteeism from work, greater productivity and less sickness benefit payments.

Research is a good thing all round and this Bill is a great opportunity to make sure we gain its full benefits. Amendment 39 emphasises the need for the Secretary of State to take his expressed desire to support research seriously and I strongly support that amendment. Amendment 199ZA, in my name, brings the same pressure on to the clinical commissioning groups and alters the wording in exactly the same way. It is at this level where I fear we have seen one of the biggest obstacles to promoting clinical research up to now. The same survey I mentioned earlier showing that patients are keen to be involved in research also showed that GPs by and large were antipathetic to and at best uninterested in research. Few GPs engage in research directly themselves, but that is not the main problem. It is their unhappiness at having to spare any time, for example, in seeking the approval of their patients for them even to be approached by researchers and asked for their consent.

Researchers have to ask patients for consent but can do so only if the GP asks the patients for them first, and they are not at all keen. They say that there is not enough time. Yet their role is critical, not only to facilitate clinical research performed by others but to be responsible, through the CCGs, for commissioning those extra support costs that arise when research, funded by charities, the MRC and so on, is carried out. Research on patients supported, for example, by the British Heart Foundation or Cancer Research UK, often results in additional costs due to extra visits or more routine blood tests. Traditionally these should be funded by the commissioners of services. This Bill provides just the opportunity we need to make sure that those at the coal face, responsible for commissioning, can facilitate and fund this research.

I hope the Minister will consider the need to accept this or a similar amendment and examine how we might provide the inducements necessary to GPs and CCGs. A failure of CCGs to take on responsibility for creating the right environment in which we can gain the full value of external funders will be damaging.

I come now to the difficult issue of the use of patient data. How can we make sure it is possible to use clinical information about patients for research purposes? New Section 14X, to be inserted by Clause 23, describes the duties of clinical commissioning groups to promote research and includes the need to promote the use of evidence obtained from research for improving the health service. That is very good, but it says nothing of the other way round; of how we can use patients’ data for research purposes. The amendment in my name, Amendment 199ZA, emphasises this point. The difficulty has been well rehearsed: how does one gain access to identifiable information about patients for research into their diseases while at the same time protecting their confidentiality and giving them all the reassurances that they need? It so happens that well over 90 per cent of patients are happy for information about them to be used for research, but the current system of safeguards goes well beyond the requirements of the Data Protection Act and is stifling much important research.

When data about patients are fully anonymised—a horrible word—and it is impossible for anyone including the researchers to identify a patient, then there is little or no trouble. However, when it is necessary for the researchers to know who the patients are, we get into problems. If, for instance, a researcher needed to use the cancer registry to look at whether patients with a given cancer were subject to some factors in their environment—for example, whether they lived near electricity pylons or some hazardous waste plant—then they would need to seek consent from each patient. But what if many have died in the mean time or are untraceable because they have moved away or gone abroad? It becomes impossible to do the research. The National Information Governance Board was set up for this purpose, but it is no more. I know that the Government intend to try to help with this now. I know that as a first step the patient information leaflet produced by the UK Clinical Research Collaboration, explaining how data about them can be used, has gone out to GP practices in Scotland and soon will be sent out in England and the rest of the UK. That is an excellent start. The Clinical Practice Research Data Link has also been set up, but I wonder whether the Minister can say how far we have got with that? Will it achieve what is needed: the rapid access to data for researchers with the approval of patients? Meanwhile this amendment seeks to flush out the need to address this hurdle to some important research.

Amendment 41 brings up the important issue of funding for public health research. Here I speak as a former chairman of the Public Health Laboratory Service, the forerunner of the Health Protection Agency, which is also disappearing. I cannot speak too highly of the marvellous work it did and does in protecting the public’s health. It is a fantastic organisation. It works on outbreaks of food poisoning, epidemics of flu and immunisation programmes against a whole host of infections, to say nothing of its work in radiological protection and on all sorts of biohazards. The point is that this organisation is at the forefront of its field and is the envy of the world because it is able to do fantastic world-leading research. It is highly dependent on a continuing research effort to keep ahead of the infections and other hazards that are continually evolving. It is vital that it continues to have access to research grant funds, particularly external grant income from the whole range of potential funders to which it has access now, such as the Medical Research Council, the Wellcome Trust and so on. I hope the noble Earl will reassure us on this. His Written Answer to the noble Lord, Lord Willis, yesterday did not give any confidence that the Public Health Laboratory Service will be able to apply to external bodies for funding.

Then there are the directors of public health and their teams. They, too, should be enabled to conduct high-quality research. The amendment makes that clear. How will they receive the necessary support and encouragement when they transfer into the local authorities? It is not at all clear that local authorities are keyed into this, so some reassurance on this point would be helpful. Most of these amendments are probing—I think they all are—and seek simply to gain a greater understanding of the ways in which I hope the Government will support the research effort.

[Lord Ribeiro]

My Lords, I shall speak in support of Amendments 40 and 42, which, as the noble Lord, Lord Willis, said, are very much appreciated and welcomed. They reflect the Government’s acceptance of the importance of research and making this an express duty on the Secretary of State.

Some years ago, Professor Sackett made the medical profession aware of the term “evidence-based medicine”. I should like to think that we have all adopted it in our clinical practices over the years. As a surgeon, I speak from a surgical perspective. In the 18th century John Hunter was approached by Edward Jenner with his dilemma about children in Gloucestershire who were being afflicted by cowpox. He wrote to John Hunter, saying, “I’m thinking about doing something about this and would like to cure the children in this area with a vaccination made from cowpox”. John Hunter replied, “Don’t think about it, do the experiment”. We in surgery consider Hunter the father of scientific surgery but our problem is that we are, perhaps, not quite as cerebral as our physician colleagues. All they have to do is learn the discipline, acquire the knowledge and prescribe the tablets. On the other hand, we not only have to learn but must then apply our knowledge in carrying out the operation. There are two skills that we must acquire. For us poor surgeons, it is often a long sentence—spent not only in a laboratory but in the theatre, putting into practice what we have learnt.

Earlier, a noble Lord—I think it was the noble Lord, Lord Warner—used the term “from the bedside to the bench”, which is very important. The whole concept behind translational research has been to get our trainees and doctors away from idea that all they have to do is stay in the lab, beavering away. It is about the patient. One of the things that surgeons try to do is take a problem from the bedside into the lab, apply stringent tests to it and then bring it back in the form of treatment, which might be by medication or an operative technique.

--- Later in debate ---

[Lord Warner]

I think that I got out in time.

[Lord Ribeiro]

I rather suspected that the noble Lord did. That is why I felt able to make that reference. None the less, I launched a big campaign at the time because here was a budget—part of the NPEC budget—for nurses, doctors and so on that was being raided. It should have been a ring-fenced budget for training, yet the money was taken out of that budget to meet the NHS deficit. There is a real danger for the present Government if a situation should occur whereby the £1 billion budget—and there is no reason why it should be more than that—that has been set aside for research, particularly as the Secretary of State has taken responsibility to promote research, was found to come under the auspices of the chief executive of the NHS Commissioning Board, and that at times of trouble and trial that that money could be used.

I wanted to speak in line with what I said yesterday, although some noble Lords may doubt that I have spoken briefly. However, I speak in strong support of Amendments 40 and 42.

[Lord Patel]

My Lords, my brief is brief—and I shall be brief. First, I congratulate the Government on putting the need to promote medical research at the centre stage of the Bill. We have criticised a lot of things and we may criticise some more, but the recognition that medical research is important to improve healthcare has been stated throughout the Bill.

It would be surprising if I said that I do not support these amendments—I support every one of them. By the way, I say to the noble Lord, Lord Ribeiro, that he was lucky that the noble Lord, Lord Darzi, was not in his place when he said that surgeons do not do research. He might have given the noble Lord, Lord Ribeiro, a tour around his department.

[Lord Ribeiro]

I gave a historical perspective. We started research in the 18th century. We may not have done it as well as the physicians, but that is when we started.

[Lord Patel]

I should also tell the noble Lord that his laparoscopic training is also historical because robots are used now.

I have brief comments, but I shall focus particularly on the amendment in the name of the noble Lord, Lord Warner, that refers to the need for informatics to be properly established to promote research in healthcare. One of the key areas in biomedical and clinical research in the UK is focused on translational research, as other noble Lords have said, to try to get research into clinical care.

Informatics plays a key role in our ability to do translational research. There are three domains of informatics in biomedical research—biomedical informatics, medical informatics and translational research informatics. Translational research informatics is about getting multidisciplinary research into clinical practice, with clinical trials being the first step to it. As we have heard, we have notable successes from our medical research into clinical translation. I say with hesitation that we think we are leaders in the world, but we are not quite the leaders—although we come pretty close. However, we can do better, and to do so we have to have what is required to promote research and its use into translation. Therefore, we will have to develop all three domains and incorporate what we already have—health information involving the medical records to which the noble Lord, Lord Warner, referred, and the development of electronic medical records. I know that other amendments address that issue. We should also be able to carry out statistical analysis.

The noble Lords, Lord Willis and Lord Warner, referred to the rapid sequencing of the genome—whole-genome sequencing—that will impact on the whole of medicine. Recent rapid developments in DNA sequencing technologies have dramatically cut the cost and the time required to sequence a human genome to a point that it will soon be easier and cheaper to sequence each patient’s genome and keep it in their notes. Every time they are diagnosed with or treated for a disease, a genome will be used to extract information. By combining that with our advancing understanding of genes and diseases, whole-genome sequencing is set to change the current clinical and public health practice by enabling more accurate, sophisticated and cost-effective genome testing.

Understanding the health impact of individual genomic variance presents a considerable challenge for analysis, interpretation and management of data. Managing that data will require bioinformatics to be established. The NHS should urgently develop clinical bioinformatics expertise and infrastructure to ensure clinical technical support for medical analysis and interpretation of genomic data. The amendment of the noble Lord, Lord Warner, that includes informatics is crucial in identifying that. If we are to succeed in applying the results of our research to patient care, we need to establish all these issues.

I should briefly mention Amendment 74 in my name. The noble Lord, Lord Willis, mentioned research in public health, as did the noble Lord, Lord Turnberg. My amendment relates to Clause 9 on,

“Duties as to improvement of public health”,

and the functions of local authorities and the Secretary of State as to improvement of public health. The amendment merely tries to,

“establish promotional research, and acting on research evidence into the causes of ill health”.

It is important that local authorities recognise that public health directors should be involved in research in the agenda that is being developed in the prevention of disease. Those are my brief comments.

Health and Social Care Bill

Lord Ribeiro Excerpts

Monday 7th November 2011 Lords Chamber

This clause, which fundamentally is a great improvement on what has gone before, is important because it gets the matter into the Secretary of State’s duties. The phrase “have regard to” is quite powerful but I wonder whether it quite reflects the determination that we have all felt over the years when we have read the work of Michael Marmot and various groups, going right back to the Black report, and to ask why we do not have something a little stronger that gives teeth to local commissioning groups to examine these issues very carefully locally.

[Lord Ribeiro]

I want to pick up on something that the noble Baroness, Lady Greengross, mentioned; namely, elderly patients perhaps being denied treatment. There is a real danger in not recognising that the clinical decision is based on the quality of the patients rather than their age, which is important. We are all aware of 60 year-olds who are basically crumbling with significant code morbidity and who would not be considered for surgery. Yet, there are many fit and self-caring people in their late 80s who may fracture a hip and would be worthy of surgical treatment. In fact, many people in your Lordships’ House in that age group may have benefited from that type of treatment. It is very important that we should see this in the context of clinical need rather than just one of age.

Similarly, as regards cancer and the point I made about the older generation, not that long ago in the United States a carcinoma of the prostate was open season for anyone to have a radical prostatectomy practically at any age, be it 80 or 90 years old. The morbidity and mortality associated with that radical surgery was very high. The American College of Surgeons, at recent meetings I attended, recognised that patients over the age of 75 should not be offered this type of surgery unless there is a very good reason. It is also a well known fact that 80 per cent of males aged 80 and over actually have—not just probably have—carcinoma of the prostate. But on whether they should have treatment for it, they are more likely to die from other conditions than from their cancer. Although age is important, it should not be a specific criterion for determining whether treatment is given or not.

[Baroness Tyler of Enfield]

My Lords, I, too, should like to speak in support of this raft of amendments which are all designed, to use the words of the noble Baroness, Lady Murphy, to give greater teeth to reducing health inequalities. We have already heard various statistics from a number of noble Lords and those for life expectancy are generally the most stark. The statistic that means the most to me relates to London, probably because that is where I live; namely, that the life expectancy of men ranges from 71 years in one ward in the London Borough of Haringey to 88 years in one ward in Kensington and Chelsea. That is a huge difference of 17 years. It is worth also pointing out that even within Kensington and Chelsea, there is a difference of nearly 12 years in life expectancy across different parts of the borough.

As many noble Lords have said, there is a whole range of reasons for this, including the social and the economic. It is one of the things that underline the critical need in our debates to put more focus on public health interventions. I also very much welcome the establishment and the role of Public Health England, and the fact that the public health function at a local level will sit with local authorities.

In discussing the need to strengthen these duties, it is important to recognise and welcome that having explicit duties placed for the first time on the Secretary of State, the NHS Commissioning Board and the clinical commissioning groups is a landmark, representing a major shift from the current position. There is something very significant about the whole raft of these NHS reforms.

The phrase “have regard to” health inequalities for the clinical commissioning groups is not sufficient because we need to make sure that they act and behave to secure real improvements, which need to be in both access to NHS services and in outcomes. I want those CCGs to account publicly for their progress, not simply as part of normal accountability but as part of sharing good practice and workforce development, and in the training of NHS employees. It should become part of the everyday currency and language of the NHS, part of the DNA of the way in which the health service operates. I believe that this strengthening is necessary if the NHS reforms are to become a real game-changer for some of the most disadvantaged group in society—to borrow from the words of the public health White Paper, Improving the Health of the Poorest Fastest.

Perhaps I may give an example in relation to homeless people who experience some of the worst health inequalities of any group in society. They are more likely to die young, live with a long-term condition, have multiple health problems and have mental health or substance use issues. They are also far less likely to have regular contact with a GP or other health professional and are much more likely to access healthcare through A&E, which is inappropriate and, as we know, causes all sorts of problems for A&E departments. In short, they are the most likely to have very poor health and the least likely to benefit from what the NHS has to offer.

Of course, many services are needed to help homeless people to improve their outcomes, including housing, employment, family support and other things. But it is particularly important that the NHS is able to cater for the needs of these groups. Appropriate services are far more likely to be commissioned where clinical commissioning groups have a duty to take account of these health inequalities in their plans and reporting mechanisms and the standards to which they are held to account, and that they are ensuring that these arrangements are incentivised through the commissioning arrangements.

I very much support the principle of the amendments put forward and I look forward to hearing the Government giving an even stronger commitment to tackling health inequalities and to making this a key outcome of the overall package of reforms that we are discussing.

Health and Social Care Bill

Lord Ribeiro Excerpts

Monday 7th November 2011 Lords Chamber

[Lord Walton of Detchant]

My Lords, 53 years ago, after seven years in full-time clinical research followed by 18 months as a first assistant in a neurological department with an honorary senior registrar contract, at the age of 35 I was appointed as a consultant in the NHS. But since at the time I had not even reached a salary of £2,000 a year, on being appointed as a consultant I chose to take a maximum part-time contract to do limited private practice, if only for financial reasons. In fact, it was a very interesting experience. I did this only for a few years before I became a full-time academic.

At that time every NHS hospital had a private ward or had the opportunity, as was the case in the regional neurological centre in Newcastle Upon Tyne, such that on my ward of 28 beds I was entitled, if I so wished, to use four single rooms for private patients. The advantage of that arrangement, which was widespread throughout the country, was that the consultants working in that kind of hospital had the right to be geographically whole-time at the hospital. They were not being diverted away to distant private hospitals. They could look after their patients, both private and public, on the same ward and give them equal standards of care. The only real advantage for the private patients was that they had single rooms.

Many years later, along came Barbara Castle, who was the Secretary of State for Health and who later became the much respected Lady Castle. By that time I was a full-time academic with no private practice. I took private patients under my care into hospital, as I had to do if they came from overseas. In order to take advantage of the research facilities in my department, they had to be treated as private patients. However, under pressure from the trade unions, the Government worked through a process of gradually removing private patient beds from NHS hospitals so that, in the end, in the three major hospitals in Newcastle Upon Tyne we had one private bed in each hospital. The result was that, as an academic with major research facilities for the investigation of neuromuscular disease, I had to refuse patients referred to me from the United States, Canada, Australia and elsewhere because there were no private hospitals which could provide the facilities needed for the investigation of these patients, and there were no private beds into which they could be admitted. I look back on the period before that, when there were private beds in NHS hospitals, with great interest. I think that it was an excellent arrangement.

This is why I strongly support the proposal that the cap on private patient beds in NHS hospitals, foundation trusts and so on be removed, but I agree that there should be a restriction so that the opportunity for such beds to be established for private patient care must not be excessive. However, the advantage is that the NHS will gain substantially from the income derived from those private beds. The noble Lord, Lord Phillips, has enunciated the principle that the standards of clinical care for public and private patients in those hospitals should be entirely comparable. The only advantage for private patients would be a better standard of accommodation, as Amendment 299B indicates, which is wholly acceptable. The quality of medical care should be identical. For that reason, I support the principle.

On the other hand, the wording of Amendment 30 is not satisfactory. Although I accept the principle of equal standards of clinical care, the amendment would make it impossible to provide the improved standards of accommodation to which Amendment 299B refers. The principle is important and I would support it in general, but the amendment needs a little adjustment.

[Lord Ribeiro]

My Lords, I agreed with everything that the noble Lord, Lord Walton of Detchant, said. His historical perspective reflects my own experience, both as a young trainee working at the Middlesex Hospital, where we had a separate private wing, and then post the decision made by Mrs Barbara Castle when the private wings lost their beds. The net result was that, when I became a consultant in 1979, there were very few private beds in my own hospital. I was a maximum part-time consultant as well. We saw a proliferation of new private hospitals in Brentwood—the Nuffield—Chelmsford and Southend; the whole area sprouted new private hospitals. I would see my private patients at the beginning of the day and then again at night while fulfilling my NHS commitment, which I am quite happy to say I did. I could travel 100 miles in a day seeing private patients, whereas previously those patients were in the same hospital. The junior doctors knew where the consultants were and if there was a problem on the ward they could consult them and bring them back.

There is another dimension to moving private beds out of the NHS, which is that I used to be able to take my trainees with me to the private hospital to assist me with my operations. That was a level of learning that they would often not have the opportunity to access, particularly if it was related to overseas patients with conditions that they had not previously seen. It was a learning opportunity which is now more or less lost. Junior trainees are very rarely able to escort their consultants to work in the private sector.

As to the private cap, it will not surprise your Lordships that two big hospitals in London, the Royal Marsden and Great Ormond Street, have a massive number of private patients who seek treatment from those hospitals because they are the best in the world. A cap in that situation is against the best interests of those hospitals. Robert Naylor, the chief executive of UCLH, has been quoted as saying that it is entirely transparent where the money from private patients treated in the NHS goes: back into supporting services within the NHS. Maintaining the cap on private earnings in the NHS will damage the NHS. Patients who come in to have their treatment privately in the NHS are treated by consultants who treat both NHS and private patients. There is no difference between the two. To deny those hospitals the opportunity of attracting patients from overseas and the benefits going back to the NHS would be a disservice.

I have looked at this amendment and, clearly, the intention is to ensure equality of care. I was watching the monitor upstairs in my office and heard the introduction to this debate. I am sorry that I was not here. The meaning behind the amendment is right. There should be equality. I am not sure whether it can be achieved in the way that has been described. The noble Lord was quite right in saying that the clinical treatment—this is not about food, beds or those sorts of facilities—that is provided should be the same.

Health and Social Care Bill

Lord Ribeiro Excerpts

Wednesday 2nd November 2011 Lords Chamber

[Lord Ribeiro]

My Lords, I am very pleased to—I am sorry; I know how difficult it is for my noble friend. Would he like to go ahead?

[Lord Newton of Braintree]

I am sorry but I am really quite slow in standing up, as noble Lords will observe.

I do not want to take a huge amount of time. I am not a member of the Alderdice-Patel-Hollins club and I will therefore not attempt to go down their professional path. I am, however, for the moment at least, a member of another club in that I chair a mental health trust—the Suffolk Mental Health Partnership NHS Trust—so I have an interest to declare. I want to express my strong general support for the basic thrust of these amendments, whatever the wording: to emphasise, in the words of the Government’s White Paper, “No health without mental health”. We need to ensure that mental illness is treated with parity in these matters, so far as we can.

I will make only another couple of observations. First, it is worth remembering that one of the notorious pressures on A&E departments at the moment is people turning up with mental illness problems, in effect, and needing the attention of mental illness specialists. This spills over and crosses the boundaries. I still think it right that there should be separate mental health trusts, but we need to recognise these linkages. Secondly, we need to recognise that this is an area in which integration with social services is particularly important. Integration is key because of the extent to which mental illness services are provided not in hospital but in the community and on a combined operation. As an aside which we will return to, the CQC needs to improve its act in terms of assessing community services for the mentally ill, which in my view it is not at present sufficiently equipped to do. That is a point we shall come back to. My main point is strong support for the principal thrust of these amendments, which I hope my noble friend will feel able to accede to.

[Lord Williamson of Horton]

My Lords, briefly but warmly, I support Amendment 11, which seems to me to be desirably explicit and logical in the structure of the opening clauses of the Bill. It is desirably explicit because, while I am sure that the Minister actually wants continuous improvement in the quality of service in connection with the prevention, diagnosis or treatment of physical and mental health, those words do not appear in Clause 2. There remains in the wider public some feeling that mental health has a lower priority than physical health. I believe that there has been a huge improvement in the priority given to mental health—I have a lot of experience of that because of my family circumstances—but the feeling I have referred to exists. Therefore, to be explicit on mental health in this clause is good.

The amendment is logical in the Bill because under subsection (1) of the new clause in Clause 1:

“The Secretary of State must continue”,

to promote,

“a comprehensive health service designed to secure improvement … in the physical and mental health of the people of England”,

yet we do not have that phrase in Clause 2, where we come on to,

“improvement in the quality of services … in connection with … the prevention, diagnosis or treatment of illness”.

That directly contributes to what is expressed in Clause 1, so we need to carry over that phrase and avoid its omission in Clause 2. That is why I support this amendment.

[Lord Ribeiro]

My Lords, I will be brief on this. I strongly support the amendment because it is important to recognise that mental health and acute clinical health go hand in hand. Most hospitals throughout the country started with psychiatric services outwith the main hospital buildings. Over many years we have tried desperately to integrate the service. We no longer have the concept of the psychiatric Bedlam that was the case in the past.

For the last five years or so of my clinical practice, a rotation of junior doctors came to work for me. They would spend four months on general medicine, four months on surgery and four months on psychiatry. As a consequence, I learnt quite a bit about psychiatry, although I am not sure that they learnt an awful lot about surgery. That was an example of integrated care. The importance of it is that a lot of the acute psychotic and suicidal admissions to hospital come through the accident and emergency department. They do not come through the separate door of a psychiatric unit at the other end of the hospital or in a different block. They come to the acute part of the hospital.

I am not saying that the Bill team necessarily overlooked this but, as has been pointed out by the noble Lord, Lord Williamson, if proposed new subsection (1)(a) is to refer to the Secretary of State’s duty to and responsibility for “physical and mental health”, it stands to reason that, as is currently the case, the Secretary of State delegates responsibility for the provision of the health service to the strategic health authorities and PCTs. Their successor bodies will be the national Commissioning Board and the clinical commissioning groups, so it stands to reason that those two bodies must also have responsibility for mental and physical health. It is vital that the three major groups who have responsibility for the health service in this country—the Secretary of State, the NHS Commissioning Board and the clinical commissioning groups—should all have a responsibility to deal with these two areas of healthcare, because they form part of an integrated service.

[Lord Layard]

My Lords, some years ago I had a meeting with a newly appointed Secretary of State for Health, although he was not that newly appointed—he had been there for three weeks. At the end of our conversation about mental health, he said, “You know, I’ve just realised something. I’ve been in this job for three weeks, I’ve had about 50 meetings and this is the first time I’ve heard the words ‘mental health’”. That says it all. That is how our health service is run and, unfortunately, how the priorities are set. I should just like to review four key facts to show why this is not at all satisfactory.

First, according to the official survey, one in six adults suffers from mental illness, mainly clinical depression or crippling anxiety disorders. These are serious conditions, as has been said. For example, a very good WHO study compared the debilitating effect of depression with that of angina, arthritis, asthma and diabetes. Depression is at least 50 per cent more debilitating than those conditions. That is why half of all the disabled people of working age in our country are disabled by mental illness. It is not a small segment but a massive chunk. It is the largest illness among people of working age.

However, coming to my second point, only a quarter of those who are mentally ill are in treatment, compared with more than 80 per cent of those with the kind of physical illnesses that I mentioned. Last year the chairman of the Royal College of General Practitioners wrote to his members with the question: if you have a patient who needs psychological treatment, can you get it normally, sometimes or rarely? Only 15 per cent said “normally”. That is the situation that we are in, which is shocking. The treatments that are available are good. They are recommended by NICE but simply not delivered on a proper scale, even though they are meant to be delivered according to the NICE guidelines.

Thirdly, what is even more extraordinary is that these are cheap treatments. It is quite easy to show from the experience of the Improving Access to Psychological Therapy programme, for example, that they completely pay for themselves through savings on out-of-work benefits, lost taxes, unnecessary visits to the GP and unnecessary references to secondary care. However, if we ask what commissioners’ priorities are, these treatments are of lower priority than many of those for physical conditions that are often much less disabling.

Finally, what is so extraordinary about this, as other speakers have said, is that the problems of people with mental health difficulties also rebound on their physical condition. We also know that many physical conditions rebound on mental conditions. Many physically ill people—those suffering from angina, lung disease or a stroke, for example—suffer from depression. Several proper clinical trials show that, with proper psychological treatment of these mental conditions, the physical condition will improve to the extent that all the money is, again, repaid in savings in physical care. Therefore, we should give much more priority to these conditions.

We also see cases where people are referred with physical conditions that have no physical explanation. Something like half of all referrals to the secondary sector fall into that category of medically unexplained symptoms. Again, many of those will respond to psychological treatments.

Despite all this, we all know where mental health stands in the priorities of commissioners. It counts if there is a serious risk of homicide or suicide. Then they really get to it. However, if not, it is, unfortunately, the easiest area to cut, which is happening on quite a scale at the moment. Two years ago the regulator, Monitor, recorded the fact that mental health services are cut by more than physical health services whenever there is a shortage of money. Monitor recorded this in its advice to trusts on how to budget in the future; it was part of its guidance. It is invariably the case that mental health is cut more than physical health when there is a shortage of money. It is just extraordinary. That guidance was eventually recanted but it is the reflex throughout the commissioning world. I am making the point that this is not only important but a very big thing. That is why it is important that we include the phrase “physical and mental illness”, and do so from the beginning of the Bill. If we do not, people will tend to forget mental health, as the department did for three weeks when it was briefing the then Secretary of State. I urge the noble Earl to take this amendment very seriously.

Health and Social Care Bill

Lord Ribeiro Excerpts

Tuesday 25th October 2011 Lords Chamber

In the case of prescribing, the patient wants something done and will not be told that there is nothing to be done to help him, but the poor old GP does the best he can, so he writes another prescription. If noble Lords have ever had to clear up after an elderly relative who has died, they will have discovered in the medicine cabinet loads of prescribed medicines that were never taken, never used. As my noble friend Lord Rea said, I am not suggesting for one moment that the health service is perfect, but this Bill is not the way to remedy that kind of deficiency. So I have two hopes: first, that my noble friend divides the House on this issue, because it is so fundamental that we really ought to hear the voices as to who goes one way and who goes the other. I also hope that enough noble Lords vote for this amendment so that we can start as best we can to rescue the health service that we love.

[Lord Ribeiro]

My Lords, I am grateful to my noble friend Lord Mawhinney for referring to the words, “motherhood and apple pie”, because when I first saw this amendment, that is the way it looked. When one reads proposed subsections (1), (2)—or parts of it— (4), (5) and (6), they seem pretty innocuous. However, in proposed subsection (2), we are talking about high principles, which none of us would disagree with—principles which crop up time and again throughout the Bill. Quality—something that the noble Lord, Lord Darzi, referred to in a speech a few weeks ago —equity, integration, accountability are all points that we will address in the coming weeks, and are fundamental aspects of this Bill. However, the phrase “not the market” is not a principle—it is a mechanism for delivering what one wants.

The noble Lord, Lord Peston, said that any form of market would turn the NHS into a privatised industry. May I remind him that during the time of the previous Administration, we had independent sector treatment centres? What were they if not an example of a market-driven industry? They were introduced—

[Lord Peston]

I was not a Minister in that Government, so I do not have to defend them.

[Lord Ribeiro]

At least the noble Lord recognises that it was something that happened, and that it was a market. It was deliberately introduced by the previous Government. Were it not for the fact that NHS consultants were excluded from working in that area, it achieved the objective it was designed to do, which was to reduce waiting list numbers. However, it was a market, so if we were to accept proposed subsection (2), we would effectively say that we must call an end to all forms of privatised healthcare provision that currently exist in the NHS. I think that noble Lords would agree that this would not be acceptable.

Proposed subsection (3) talks about restructuring and reorganisation. The noble Baroness, Lady Williams, addressed this very effectively when she said that we do not want to encapsulate the NHS in aspic, creating rigidity rather than flexibility. The previous time the House debated the health service, I made reference to the decision that had been made on Chase Farm. It had taken 17 years for it to be made. If we were to accept proposed new subsection (3), effectively every constituent of Chase Farm would have a very good legal reason to challenge why that reorganisation had taken place. While I am fully supportive of the idea in Amendment 52 of having the NHS constitution clearly laid out—we all agree with, understand and support it—I am not in agreement that the five principles as set out in Amendment 1 should be accepted in their present form. If it came to a vote, I would certainly oppose the amendment.

[Lord Bichard]

I have some sympathy with the suggestion that we should set out at the beginning of the Bill the values and principles on which the service is based. My difficulty is that I fear the amendment is not appropriate or adequate in its current form. Therefore, I will be unable to support it for reasons that other noble Lords have given, and for two others in particular.

First—and others may find this provocative—the NHS is still not driven often enough by the primacy of patient care. It is not, therefore, enough to say that the primacy of patient care will not be compromised by structural or financial reorganisations. We should surely be much more positively committed to the need to redesign services around patients, and I thought that that was one of the major purposes of the Bill. It is difficult to believe that in a modern world we can be content that people should stay in accident and emergency departments for four hours and longer. That is a question not just of resources but the way in which we design the service and the primacy we give to the patient. We cannot be comfortable that that is happening enough. I agree that we should not have more structural reorganisation, but that in itself is not enough. We should positively redesign our services.

The second reason why it is difficult to agree with this particular amendment is that if we are going to have a clear statement of values and principles, they should be clearly directed at the commissioning agent itself—the service—not to contractual providers. They should be built into contracts and specifications, and the service should ensure that these are taken seriously. I am afraid that the amendment seems to be muddled in that respect, and we cannot expect people performing functions to behave in a way that the commissioning agent is not specifying and requiring. Therefore, the values should be directed primarily at the commissioning agent.

I regret that I cannot support the amendment; I would like to see a clear statement of values early in the Bill, but this is not it.

--- Later in debate ---

[Lord Turnberg]

In speaking to these amendments, I am conscious that we are hamstrung by the fact that we have an education and training regulation or Bill to follow. So there is much to come. However, education is so important and so much an integral part of every aspect of the NHS that we must have some recognition of that in this Bill. It is just not possible to imagine a health service run by an uneducated workforce. I am obviously in support of all these amendments, and I am delighted that the Government have got their own helpful amendment in there, but there is much that remains to be clarified. I hope that noble Lords will forgive me if I go over some of these just a little. I should state my own interests of having spent most of my working life deeply involved in undergraduate and postgraduate medical education.

It is vitally important for the Secretary of State to take on responsibility for education and training in the NHS. It is how that responsibility is fulfilled that I want to focus on, by examining where the potential risks lie in this Bill to the system that we currently have in place and, indeed, where we might take advantage of the Bill to look for improvements in the way that we operate now. I will concentrate on medical education as the system I know best.

At the moment, GPs and hospital specialists are trained using a range of curriculums designed and delivered by the medical royal colleges. The colleges assess the trainees and set their exams, and all of this has to be approved by the General Medical Council. The GMC is the competent body set up under EU law that has to ensure that the training programmes reach the minimum standards set by the EU. It has to be said that in the UK we are way above those minimum standards. All of that is relatively straight-forward. But most of the actual delivery of all this training has to take place locally, at GP practices and hospitals. It is here that we have to be very careful as the NHS moves into its new mode of working.

At this level, the royal colleges have oversight of training through their own regional adviser network, while the postgraduate deans and their teams make sure that the conditions for training are right and that the trainees go through the programmes supervised by local programme directors. They are available in every major discipline and speciality. So there is a complex network for direct oversight of postgraduate education which currently works reasonably well.

However, it is the deans who carry the heavy responsibility of the budget for salaries for all of the trainees. They pay their salaries and they can, theoretically, withdraw funding for trainees if trusts fail to provide the right conditions for training. So the postgraduate deans are absolutely critical and yet their role is threatened as the strategic health authorities which now employ them seem to be disappearing. The deans have enormous power, and budgetary responsibility, but where will they go, and who will appoint and employ them now? I believe that it makes a lot of sense to think about them being employed somehow by the proposed new Health Education England when that is set up, but meanwhile it will be critically important not to lose them. Uncertainty about their future is not a good recipe for them to function effectively. They need some certainty now.

Leaving the deans aside for the moment, it is clear that the current system is dependent on close-working collaboration between them and the royal colleges, the GMC and, at the local level, the consultants and GPs doing the training. All this is going on in an NHS busily providing services for patients at the same time. This is the second threat to education, because it is increasingly evident that the service pressures on consultants and GPs are limiting their capacity to provide the teaching. They are increasingly feeling that the time available to teach is being eroded as service pressures build up. This is not a new phenomenon, but one that is more obvious now. The fear is that this will get worse unless—this is the key—we place a duty on the commissioners of the service for them to fund the extra sessions that consultants need to teach their trainees. One alternative might be for the postgraduate deans to have a budget for these sessions, but I suspect that this would not meet with much favour. I personally am not moved by it. It is a responsibility that we have to place on the commissioners.

Finally, I want to mention the public health doctors and their training in the brave new world. They are in some disarray, as I understand it from the public health doctors themselves. The directors of public health are to be transferred to the employment of local authorities. That makes some sense, at least on the face of it. But there may well be difficulties. They may find that the local authority terms and conditions are significantly different from the NHS terms. That may affect recruitment and retention. I have a fear of a return to the days of the medical officer of health, who was in the local authority, rather a rather sad figure remote from the medical community at large. However, rather more important is the training and education of public health doctors. It is quite unclear where the local authorities sit in relation to meeting the needs of those trainees in what is a vital medical discipline. It may be that all of this has been thought through. If so, it would be helpful to hear about it. The public health community certainly needs to know.

Meanwhile, I think that a better solution all round would be for the public health doctors to be employed by Public Health England and for them to be seconded to the local authorities. That might be more satisfactory all round, and it would give some security to the education and training of this key professional group.

I have not spoken about nursing education, not because it is not important—it clearly is—but because we are coming to it later in the Bill, and at least some aspects of nurse training and education will come in later clauses. I am sure that we will return to that. For the moment, I want to support this group of amendments, including that of the Government. But it seems entirely possible, I fear, that there will be further amendments at a later stage to try to tease out some of the issues I have been discussing.

[Lord Ribeiro]

My Lords, I thank the noble Lords, Lord Walton of Detchant and Lord Patel, for introducing this amendment. It highlights not only the importance of education and training in advance of the report that we will receive later in the autumn from the Future Forum group, but the fact that the Government have responded with an amendment of their own. That identifies the importance of bringing it on to the face of the Bill, so much so that it is right at the very beginning of Part 1. It is one of six duties that the Secretary of State now has to perform. That is very important.

It is quite understandable in a Chamber such as this one, full of doctors, that we tend to overemphasise the importance of medical education. As the noble Lord, Lord Turnberg, rightly said, nursing will be discussed later. However, it is not just about nursing. My wife is a physiotherapist—there are physiotherapists, radiographers and other healthcare workers as well. That is why the Government’s amendment talks about education and training without qualifying exactly which areas we are discussing. It is important that we bear that in mind.

The noble Baroness, Lady Finlay, I think, referred earlier to the independent sector treatment centres and the lack of training in that area. I must declare an interest as a past president of the Royal College of Surgeons. I had countless negotiations with the Department of Health to put into place a requirement for independent sector treatment centres to be able to train. The big issue was that all the surgeons and the ISTCs were overseas doctors. No UK doctors were allowed to train. We asked for a way in which we could introduce NHS consultants into what was effectively spare elective capacity. I fundamentally believe that we must separate emergency and elective surgery to produce the best-quality care for patients.

As a consultant, I would regularly do an out-patients’ clinic at Basildon hospital on Mondays. If I was also on call, as I sometimes was, I could be told that there was a patient in the emergency department who needed urgent treatment. That would ruin my out-patients’ clinic because I would have to go to theatre and sort out that patient. Our last assessment showed that 64 per cent of the general surgeons in Great Britain and Ireland have a responsibility to be on call while they are doing elective work. If you have that degree of commitment to doing two things, you cannot provide the best possible care for your patients. If NHS consultants could structure their work so that it was possible to work in a centre which was perhaps in the hospital—there are a few hospitals, including one in Nottingham, with elective centres within the hospital—or perhaps outside, they would be able to take their registrar and SHO to the independent sector and they would be able learn how to carry out the surgery.

[Baroness Finlay of Llandaff]

Perhaps I may ask for clarification from the noble Lord. I am not sure whether he is advocating that the duty in the government amendment should or should not be on every provider, whichever sector it is in. I tried to make it clear that I felt that the duty to provide education should be on everyone who provides patient services. I was hoping that the Minister would clarify that that was what was in the Government’s mind, so that history—what had happened before—could not be replicated.

[Lord Ribeiro]

I accept that point, although it might be difficult to implement when you consider the third sector and the voluntary sector, which may not be in a position to undertake education and training. That is a point to bear in mind.

[Baroness Finlay of Llandaff]

Forgive me but, as someone who works hugely in the voluntary sector and is a patron of many of the healthcare providers, perhaps I may point out that they carry out a great deal of education. An example is Marie Curie running NVQ courses for care assistants across the whole country. They are trying to drive up the standard of care given by people who are absolutely not at the medical end but whose care is critical to the quality of service that patients receive.

[Lord Ribeiro]

The noble Baroness makes her case but there is a wide spectrum of medical provision, and the question is whether this could be applied to every single provider. I am not clear about that but perhaps the Minister will be able to address it.

Returning to the question of training, I believe that through the Bill there is an opportunity, perhaps when the contracts for some of the independent sector treatment centres are up for renewal, to give some serious thought to whether these centres could provide the extra capacity that the NHS desperately needs if it is to go forward with the functional separation of emergency and elective care. I am of course talking about surgery and I recognise that that is a special case. None the less, we come from a history of one type of surgical provision to the situation in this Bill. If we are talking about quality as the indicator of the outcomes that we are looking for, it may well be possible to achieve this by utilising the ISTCs for NHS consultants. I shall give way if the noble Lord wishes to speak.

[Lord Winston]

I had no intention of interrupting the noble Lord. I merely thought that he was concluding his remarks and I was going to follow.

[Lord Ribeiro]

I take the distinct hint that it is time to conclude my remarks. I merely wish to say that we have an amendment in the Government’s name. It may well have been prompted by noble Lords introducing their own amendment, but the fact is that it is now there in the Bill.

[Lord Winston]

My Lords, I was interested to hear that the noble Lord, Lord Ribeiro, thought that the Chamber was full of doctors. I suspect that if we were discussing a legal matter, it would be full of lawyers, or if it was a matter relating to the City, it would be full of industrialists and so on. It depends on the nature of the Bill. It is very good that the Chamber is currently full of doctors because, like the noble Lord, Lord Ribeiro, we can give special credibility to the discussions and amendments that we are trying to tease out. It is a pity that there are not more members of the nursing profession in the Chamber, as well as others who are involved with healthcare and its wider applications.

--- Later in debate ---

I could go on but I will not. I just want to deal with what is becoming an urban myth about private providers of elective surgery services and their attitude to training. For my sins—it is a good confessional evening for me—I was responsible for negotiating wave 2 of the ISTC programme with the private sector. The private sector wanted more training responsibilities. It had been cut out of training in wave 1—a mistake—and it wanted training because it thought it would get better doctors working in its centres if they had a training function. Doctors in those centres wanted to see doctors in training, watching them and learning their trade in that setting, because those centres would be doing a very high volume of elective surgery, so you needed to use that. It has been put about in some rather strange way that the private sector did not want to do that. Frankly, it was not even in its commercial interests not to do that, so it is becoming a bit of an urban myth that it was trying to duck its responsibilities in the area of training.

[Lord Ribeiro]

I should just like to acknowledge that the references that I made earlier were to wave 1. I fully recognise and appreciate the work done by the noble Lord, Lord Warner, in trying to get a training contract with the private sector. However, there was a determination on the part of the Government when ISTCs were first introduced to keep the NHS consultants and trainees out of those centres.

[Lord Warner]

I ought to make clear that I was not launching an attack on the noble Lord, Lord Ribeiro, with whom I had an excellent relationship as a Minister when he was president of the Royal College of Surgeons.

I finish by saying that although we are making progress on this Bill by having amendments of this kind early on, it is important to realise their limitations. A number of noble Lords, particularly my noble friend Lord Turnberg, have raised a whole raft of issues which still need to be grappled with. This may be the first of a number of debates we have on the issue of education and training as we try to strengthen the Bill in this area.

Health and Social Care Bill

Lord Ribeiro Excerpts

Tuesday 11th October 2011 Lords Chamber

[Lord Ribeiro]

My Lords, I am pleased to follow the noble Lord, Lord Mawson, with his robust defence of entrepreneurship and innovation. The Health and Social Care Bill presents a once-in-a-lifetime opportunity to deliver a patient-centred health service. The Bill builds on the reforms of the last Labour Administration, but in a much more comprehensive manner. As a surgical registrar at the Middlesex Hospital in 1972, ward rounds consisted of doctors, nurses, physiotherapists, social workers and the lady almoner. Coffee in the sister’s office provided an opportunity to plan the progress of patients from hospital to home care and support in the community. This was an example of hospital care working closely with social care. Subsequent reviews and reforms of the NHS have entrenched the separation between social care and health care, and this Bill addresses a need for an integrated service led by clinicians who should have a greater say in how the service is commissioned and delivered, but must also be prepared to accept the responsibility and accountability that this autonomy provides.

For too long, political interference in the day-to-day management of the NHS, occasioned by the need for politicians to account for taxpayers’ money, has bedevilled the NHS. Micromanagement and top-down diktats imposing targets and guidance, often with no sound clinical evidence to support them, have frustrated clinicians over the years, stifling leadership and innovation. I should know, because I have often been at the receiving end. The emphasis placed on quality outcome measures by the noble Lord, Lord Darzi, as he eloquently outlined today, and in his NHS review of 2008, indicated for the first time a move from politically driven targets which were process-based to evidence-based practice supported by research.

The Government’s White Paper Equity and Excellence: Liberating the NHS was widely welcomed in July of this year by the profession. It noted that:

“The primary purpose of the NHS is to improve the outcomes of healthcare for all”.

It went on to say:

“Building on Lord Darzi’s work, the Government will now establish improvements in quality and healthcare outcomes as the primary purpose of all NHS-funded care”.

Clause 2 does just that. It talks about outcomes, the effectiveness of the services, measured by clinical outcomes and patient-reported outcome—something which is already happening within surgery, the safety of the services and the quality of the experience undergone by the patient. The inclusion of research as a new duty for the Secretary of State puts an onus on him or her to promote the use of evidence obtained from research, a duty which also relates to the NHS Commissioning Board and the clinical commissioning groups. Other noble Lords will, I am sure, speak about the importance of research, but it is important that the Chief Medical Officer who, as the Chief Scientific Adviser and Director of the National Institute of Healthcare Research, must be given the independence of action to ensure that the Commissioning Board and the clinical commissioning groups take account of the evidence of research.

In a debate on the NHS Futures Forum on 15 September, I raised the issue of the independence of the Commissioning Board and the need to free it of political interference. I referred to the King’s Fund report Reconfiguring Hospital Services as an example of how hospital services can be reconfigured without political interference, making reference to the experience in Ontario. The decision to close the A&E and maternity services at Chase Farm was an example of how the evidence for reconfiguration has been available for many years—17, I believe—but the political will to use it was lacking. Freed from such pressure, the Commissioning Board should be able to make decisions which politicians find difficult to make, even when the evidence for change is there for all to see.

The White Paper also called for clinical leadership and this was echoed by the Future Forum. Now is the time for the medical profession to stand up and be counted. The Royal College of Surgeons, of which I am a Fellow and a patron, has said very firmly that the time for delay has passed. It is nine months since the Bill was first read; an in-depth review by the Future Form, taking evidence from more than 7,000 people and receiving 25,000 e-mail comments, has been accepted almost entirely by the Government and many amendments reflecting their concerns are now included in the Bill.

As a surgeon, I am aware that we must do more to deal with the demand for healthcare. Much of this relates to public health. The problems relate to obesity. Britain has among the worst levels of obesity in the world and it is increasing. Smoking claims over 80,000 lives a year, and alcohol dependency is a problem for 1.6 million people in the UK. These are all public health issues which put enormous strain on the capacity of the NHS to cope. Diabetes, cardiovascular disease, respiratory diseases and cancer are some of the non-communicable diseases which are on the increase and they require prevention rather than cure.

Public health, in the form of clean air, clean water and sanitation and vaccination against communicable diseases, improved the health of the nation during the last century. It has increased the quality and the extent of life. We need to make provision for our elderly population, through greater integration of our health services, dealing with social care as well as acute care, and focusing on a care pathway, not just the condition. The Secretary of State’s responsibility for public health is welcome and is a clear indication that the Cinderella service has come of age and can take its place alongside acute care in terms of the total care of the patient.

Like many noble Lords, I have received countless e-mails about today’s debate. An abiding theme is privatisation and the Americanisation of our health service and the threat of cherry-picking by American companies. It might be helpful to put the term “cherry-picking” in context. It was first used in a submission I made as president of the Royal College of Surgeons to the Health Select Committee of the House of Commons when we were meeting on the independent sector treatment centres in February 2006. On 10 January 2006, the Secretary of State said of the independent sector:

“But I recognise that other reasons for using the independent sector to add to the innovations already happening within the NHS and to introduce an element of competition and challenge to under-performing services is a harder argument to win, so we will continue to respond to legitimate concerns, for instance to ensure that training for junior doctors is provided within the independent sector treatment centres”—

that still has not happened—

“and more generally to provide a level playing field for different providers within the NHS”.

That was five years ago. In my oral submission to the Health Select Committee on 9 March 2006, I welcomed the Secretary of State’s statement as it sought a level playing field. “Any qualified provider”—with the emphasis on “qualified”, as the noble Baroness, Lady Jay, required—seeks to ensure that competition within the NHS will be fair. It is not a new concept and I believe that the Bill addresses the concerns raised in 2006. In Committee, I will seek to explore in more detail how post-operative complications arising from surgery by qualified providers will be managed, to ensure that they do not place an unfair burden on the NHS. For many years, the medical profession has called for an end to top-down management, targets and political diktats on health, and they remain frustrated with the workings of the PCTs.

This Bill heralds a shift from central command and control to patient and professional power. It provides an opportunity to improve health outcomes for patients and remove layers of bureaucracy which have built up, at great cost to the NHS. No change is not an option. Doing nothing will see health costs rise to £130 billion by 2015. We need to act now to safeguard the NHS for future generations.

NHS Future Forum

Lord Ribeiro Excerpts

Thursday 15th September 2011 Lords Chamber

[Lord Ribeiro]

My Lords, I thank the noble Baroness, Lady Wheeler, for introducing the debate. The Future Forum addressed four core themes, many of which she has covered: choice and competition, patient involvement and public accountability, clinical advice and leadership, and education and training. The latter, as she correctly described, is still work in process under Julie Moore, who led the forum’s work on education and training. The Government have accepted that deaneries will oversee the training of junior doctors and dentists, and that that will be under the umbrella of Health Education England. That should give some reassurance to the profession, but it remains unclear who should be responsible for quality assurance of training. I do not believe that a “one size fits all” approach works, particularly with respect to the craft specialties. In this, I include surgery—here I must declare an interest as a past president of the Royal College of Surgeons. Prior to the introduction of the postgraduate medical education and training board, known as PMETB, currently responsible for quality assurance, colleges had the responsibility for accrediting training. I believe that the craft colleges are ideally placed to undertake the quality assurance of training, ensuring professional clinical input under the auspices of Health Education England.

Turning to clinical advice and leadership, the forum called for multiprofessional involvement and leadership at all levels of the system. The NHS commissioning board is a good place to start. I welcome the Government’s statement that the NHSCB will establish close links with the royal colleges and other professional bodies to entrench partnership-working at the national level. The board will have a medical director and a chief nursing officer—rather reminiscent of the old days of matron, senior medical officer and administrator, who used to run hospitals before the 1974 reforms. The board needs to be independent and free of political interference.

The role of the Secretary of State has been clarified in the Bill. I know, after following the debates in the other House and the views expressed by the noble Baroness, Lady Wheeler, that there is still concern about the role, but I believe that it is clearly expressed in the newly amended Bill. The Secretary of State will have a mandate to provide clear direction to the board, and the board will then be accountable to the Secretary of State.

One of the biggest problems that any Secretary of State faces is the reconfiguration of services—in particular, hospital services. The King's Fund this month produced a report, Reconfiguring Hospital Services. The report highlights the urgent need for clinical reconfiguration of hospital services in some locations to improve the quality and safety of patient care. The ability of politicians to interfere with the process of reconfiguration is well known, and the sight of MPs of all political persuasions on the picket line outside hospitals threatened with closure is not uncommon. The evidence presented by Chris Ham of the King's Fund of the Ontario experience in Canada suggests that an independent body can make hard decisions. The health service’s restructuring commission set up in Ontario in 1996 to restructure hospital services not only achieved its mandate but saved $1.1 billion in a total spend of $17 billion. This amount was then reinvested in other services.

The commission drove the establishment of clinical networks, a recommendation made by the Future Forum, and invested in home care and long-term care to facilitate hospital closures where required. Chris Ham also noted that the process used was not dissimilar to that used in this country to support the closure of mental and learning disability hospitals in the 1990s. The Government then transferred funding ahead of hospital closure to develop community services.

We must learn from these lessons. The Secretary of State should not be concerned with operational matters, but should be focused on strategy. Liberating the NHS implies liberating the service to rely more on professional clinical leaders. Armed with evidence, backed by research—another new responsibility for the Secretary of State—evidence-based practice can be used to reform the health service.

I believe that delay is not an option. The impact of specialisation, and in particular the European working time directive, of which we have heard much in this House over the past few years, will make it impossible to provide emergency surgical cover in all hospitals with accident and emergency departments in England. The development of trauma centres in London will create a new paradigm shift in acute care management. Reconfiguration of emergency services will be an inevitable consequence of this change, which will ultimately affect all hospitals in England. The Darzi principles, mentioned by the noble Baroness, Lady Wheeler, are important. They introduced quality outcomes based on the effectiveness and safety of the services delivered, and the quality of the patients’ experience remains a fundamental principle on which, I believe, the Health and Social Care Bill can build.