NHS: Front-line and Specialised Services

Lord Touhig Excerpts

Thursday 13th January 2011 Lords Chamber

[Lord Touhig]

My Lords, I am pleased to be here for this debate, if only to have listened to the speech of the noble Baroness, Lady Jolly, because she spoke from the heart about the National Health Service and her family’s personal understanding of and reception by the NHS recently. She was also able to speak with some authority as someone who has been involved in the provision of healthcare. I look forward to her future contributions on this matter.

I am delighted to follow the noble Baroness, Lady Greengross, because I, too, want to relate my remarks to dementia. She does a tremendous job in chairing and leading the all-party group.

If you are a man who has had a stroke and as a result you have no recollection of the wife you have been married to for 30 years, and then you develop dementia, you have no voice. If you are a woman who one day stops talking to her family and has not spoken a word in 18 months, retreating into a valley of silence, you have no voice. If you are a dementia sufferer who is doubly incontinent and you have no downstairs shower and toilet, and the only day of the week when you can be sure that you will be made really clean is the day you go to a healthcare centre, you have no voice. As Parliament, at the behest of the Government, prepares for a major shake-up in the provision of NHS services, I believe that we must be the voice for dementia sufferers and their carers.

Three-quarters of a million of our fellow citizens have dementia and it is forecast that by 2025 the number will be over a million. I welcome the success of my noble friend Lord Turnberg in securing this debate so we can press the Government to tell us how front-line specialist services will be protected in this shake-up. We currently spend £20 billion a year on dementia and, as the noble Baroness, Lady Greengross, pointed out, one in three people over the age of 65 will die with dementia—yet currently only one in three receives a formal diagnosis. As a member of the Public Accounts Committee in the other place, I well remember a National Audit Office report in 2007 which found that money was being wasted on poor quality care. The report went on to say that rates of diagnosis were low, cost-effective interventions were not widely available, and health and social services were often disjointed and inefficient. A further NAO report this year said that the National Dementia Strategy for England, first published in 2009, was comprehensive and ambitious. It found that there was early progress towards implementation, but warned that not enough priority was being given to dementia. There has been some progress, but not enough.

I share the worries of the Alzheimer’s Society, which is concerned that the pace of structural change that is going to come in the NHS has the potential to undermine the progress we have made so far. That is all the more reason why these changes, as the noble Baroness, Lady Greengross, said, have to be managed very carefully indeed. When I was a Minister in the previous Government, I well remember the former Prime Minister, Tony Blair, saying to me that for him healthcare was not about the doctor, the nurse or the latest high-tech scanner, it was about the patient. Of course, he said, we need the doctor, the nurse and the high-tech scanner, but the focus the whole time must be on the patient—and that, I believe, is right.

Over the past couple of years, we have seen increasing knowledge and ability among many NHS commissioning managers in commissioning better and improved care for dementia. However, the number of people with these particular skills is relatively small. It is vital, therefore, that the pace of structural change which will come about as a result of the Government’s NHS changes does not undermine this progress. Valuable dementia commissioning has been developed and must be retained. Perhaps the Minister can say something about this. GP commissioning will play a major role in the future, but only 31 per cent of GPs believe they have received sufficient basic and post-qualification training to diagnose and manage dementia. Can the Minister say what specific steps the Government will take to ensure that the small pool of dementia care commissioning expertise is not lost, a point well made by the noble Baroness, Lady Greengross?

A recent survey showed that only 5 per cent of GPs had discussed the national dementia strategy with their PCT commissioners. What is important, therefore, is that the current coterminosity of boundaries for commissioning health and social care is not lost. People with dementia are major beneficiaries of effective joined-up working between the NHS and social care because they use the two services. In order to continue to meet the needs of people with dementia and their carers, can the Minister assure us that the new GP commissioning arrangements will result in a comprehensive primary care response, including improved home care, so that admission to the acute sector is used only where it is necessary?

We can only imagine what it must be like to suffer with dementia. A dementia sufferer is like a prisoner locked away by an illness of the mind in a world of their own. That is why we must be the voice for those people and their carers.

NHS: Reorganisation

Lord Touhig Excerpts

Thursday 16th December 2010 Lords Chamber

Moved By

[Lord Touhig]

To call attention to the reorganisation of the National Health Service; and to move for papers.

[Lord Touhig]

My Lords, it is a privilege to open this debate on a matter as important as the National Health Service. The NHS was the subject of my maiden speech in the other place more than 15 years ago and, like many noble Lords on all sides of the House, I feel very passionate about the service. It is easy to take this great service for granted, but we should never forget how fortunate we are to live in a country that has such high-quality healthcare available for each and every citizen, free at the point of use.

I pay particular tribute to those who work in the National Health Service. Their commitment to their patients and to ensuring the best outcomes for those whom they treat is the bedrock of the NHS. Without their dedication, the NHS would be nothing. The fact that the service provides some of the best healthcare in the world is a reflection on their professionalism and hard work. We should never lose sight of that.

We have a health service that we can be proud of and that has certainly improved over the past 12 or 13 years, but we now have a new Government who seem determined to impose their own vision on the National Health Service—a vision which, perhaps not surprisingly, is riddled with inconsistencies and risks having a negative impact on patient care. It is notable that the British Medical Association has reacted in a decidedly mixed way to the Government’s proposals. In response to the White Paper, Equity and Excellence: Liberating the NHS, which was published in July, the BMA reacted most strongly against the increased commercialisation and competition that the Government seem determined to foist upon the service. I am sure that I am not alone in sharing those worries.

Most concerning is that, despite the increased emphasis on competition in the recent past, there is still little evidence that such measures have any benefits for the patient. The Government came to power promising to make policy that was evidence based, yet expanding competition in the NHS flies in the face of that pledge. Indeed, increasing competition seems to have more to do with ideology rather than the welfare of the patient. I share the BMA’s view that high-quality care can be delivered in the most cost-effective way by encouraging co-operation across primary and secondary care.

I fear that, rather than encouraging co-operation and collaboration between care providers, the Government’s policy risks discouraging the sharing of information and good working practices. Such discouragement, it seems to me, is the logical consequence of forcing care providers into competition. It is normal commercial practice for competing service providers to keep new information or successful developments to themselves so that they can exploit them and improve their market position. Obviously, such providers do not share information that gives them an advantage over their competitors. That makes perfect sense in the commercial private sector, yet in the NHS such an approach would massively undermine the ability of care providers to adapt to changing circumstances and ensure best practice. Decreasing co-operation and collaboration would, I fear, be the natural consequence of further increasing competition in the NHS—a view that is shared by the BMA. Therefore, I hope that the Government will put patients’ interests and the views of professionals before their ideological agenda.

I am also concerned by the Government’s “any willing provider” policy, which risks exacerbating the difficulties with increased competition. The policy has the capacity to undermine local health economies by replacing existing multiservice natural monopolies with a plethora of smaller units that provide more limited services. As well as radically undermining the efficiency and value for money achieved by the NHS, that risks creating obstacles to the NHS working co-operatively for patients as a public service.

The concept of competition and of the “any willing provider” policy is supposed to allow patients to make meaningful choices about their care, but in my experience—which I am sure is shared on all sides of the House—what most patients want is high-quality providers close to where they live that offer timely and competent diagnosis, treatment and support. I fear that the Government’s policy risks undermining this central patient wish. It risks turning care providers into nothing more than businesses which, rather than supporting each other and striving for better provision of healthcare across the whole NHS, seek only to improve their own market position. If the outcome of increasing competition is to undermine the central priority of patients, I have to question the benefit of increasing competition.

The Government have also decided that they want all NHS trusts to obtain foundation status within three years. That undermines the whole rationale of the concept of foundation trusts, which was that foundation trust status was supposed to be a mark of quality and achievement. Evidently, if all trusts become foundation trusts almost overnight, foundation status will cease to be a mark of quality and in some regards will become meaningless as a concept.

The White Paper signals the Government’s intention to return to the GP fundholding scheme that we had under a previous Tory Government. The noble Lord, Lord Walton, who is held in high regard by noble Lords on all sides of the House, spoke about this in July. He said to the Minister who made the Statement on the White Paper,

“Many of those who are so proud of the NHS have major concerns about the GP-commissioning element of the White Paper”.

The noble Lord continued:

“No doubt the Minister will remember GP fund-holding under the previous Conservative Government, which was not a great success and had to be withdrawn in the end because it failed to fulfil the objectives”.—[Official Report, 12/7/10; col. 537.]

He was right. The House will not need reminding that GP fundholding, which was first trialled the last time that the Conservatives were in Government, did not work.

There are many other lessons that the Government must learn from pushing ahead with such a policy. In 1992-93, 5 per cent of GP fundholders overspent their budgets by more than £100,000. In the same year, 21 per cent—one in five—underspent their budgets by more than £100,000. Across the NHS last year, the underspend was almost £32 million—millions of pounds that Parliament voted for the health service but were not used.

There is now another worry concerning funding. In an analysis of the comprehensive spending review and of the White Paper that the Nuffield Trust published in October, the trust points out a little-noticed proposal in the spending review that would make a major change to the rules governing underspends across government and would have a profound impact for health. The NHS had a £5.5 billion cumulative underspend at the start of the financial year and plans to have a further underspend of around £l billion in 2010-11. The CSR announcement will mean that none of that money will be returned to the NHS. The Nuffield Trust said that, in effect, that amounts to a retrospective cut in health spending.

There is more. It is important in the context of GP-led commissioning that GPs are properly accountable for the decisions that they take. The big concern must be that GP commissioning will be less transparent and less accountable. Inadequate experience of commissioning a range of treatments will lead to a postcode lottery in NHS provision. For example, it would be possible for a group of GPs with a specialist interest who know where to obtain the best treatment to provide high-quality care for cancer patients. Another GP commissioning practice may have no such knowledge or specialist interest so its patients would might not be so well provided and cared for.

The Secretary of State this week attended the Britain against cancer conference hosted by the All-Party Parliamentary Group on Cancer. When the audience of health professionals, doctors, patients and politicians was asked whether GP commissioning would improve or worsen cancer care, the conference voted unanimously for the proposition that care would worsen. With great respect to the Secretary of State, he seemed not to pay much attention to that. He went on to say that GP commissioning was a chance to improve GPs’ knowledge. Turning the National Health Service upside down to improve GPs’ knowledge is one hell of a risk to take. The Secretary of State left the conference with the message that he wanted GPs to be thinking new thoughts. What in God’s name is that supposed to mean? I have no idea whatever.

So far, some 52 GP practices have signed up to become pathfinders for GP commissioning. That number could increase to 500, and those commissioning consortia would replace 150 primary care trusts. However, that leads to further problems. The NHS relies on data collection to improve healthcare. How will that be done, when some 500 consortia are doing the job of collecting the data that are currently collected by 150 PCTs?

The National Audit Office and the Public Accounts Committee in the other place have done excellent work in establishing best practices to achieve value for money across public spending. In achieving value for money, will GP commissioning consortia be incentivised to save money? Perhaps the Minister can tell us. If that is the case, what will the Government do to ensure that the NHS does not drown in a sea of medical negligence claims? If a GP consortium is incentivised to save money, there is a danger that patient care will suffer and that someone will then rush off to the lawyers—it will be a litigant’s paradise—in order to get some redress.

There is a common GP contract in England and Wales. How will the new arrangement in England intersect with what is happening in Wales? Will it mean separate GP contracts? How much will that cost and who will pay? It is clear from the response to the White Paper that many GPs lack the experience to run a commissioning service and many do not want to do so. Will they be encouraged to buy in solutions from private healthcare providers, such as the American-owned UnitedHealth or Humana, which on its website describes itself as the “Human Face of Healthcare”? Those companies are already touting for business and advertising their ability to manage GP consortia on their websites. Does the Minister agree that outsourcing the management and commissioning of health provision can, and probably will, lead to conflicts of interest? What steps will be taken to ensure that a healthcare company brought in to manage a GP consortium will not place work with itself as a healthcare provider?

Many noble Lords want to speak so I shall bring my remarks to a conclusion, but there is one further point that I should like to make. Much has been said in recent times about the enhanced role of the third sector in providing services. Earlier this week, together with a number of noble Lords whom I see in the House today, I attended a meeting of the All-Party Parliamentary Group on Stroke—stroke is the second major contributor to dementia—where we had a general discussion about the planned changes for the National Health Service. Some of the comments that were made at that meeting are worth repeating. “Left entirely to market forces, stroke will slip down the agenda”, was one view. Talking about top-down targets, another contributor commented, “If not targets, we certainly need objectives”. Another asked, “What is the future for the stroke impairment network?”. A final comment was that, “PCTs are at last understanding stroke. If we have to start from scratch again, let’s not lose the gains we have made in transition”. Those remarks will, I am sure, be repeated right across the health-supporting third sector.

The White Paper risks undermining the very fabric of our National Health Service; it risks reducing co-operation within the NHS; and it risks undermining the progress that has been made in improving patient care and outcomes. Most important, the proposals risk moving us away from a National Health Service that works co-operatively for patients as a public service—a move that I think would deeply harm patient care. Those outcomes would be disastrous for patients, doctors and the country as a whole. I hope that the Government will think again about their proposals.

--- Later in debate ---

[Lord Touhig]

My Lords, as barely a minute is left in this debate, I am unable to thank all noble Lords individually for taking part. Other than a general thanks, I cannot comment on all the points that were made. The standard of debate here was much better than in the other place. There is such wide experience, which is a huge benefit. I thank the Minister, who did very well in responding to all the questions raised by noble Lords. His eloquence does not equate to the power of his argument, as those who expressed doubts and questioned these changes won the argument. I have no doubt that we will return to these issues.

Motion withdrawn.

Autism

Lord Touhig Excerpts

Tuesday 7th December 2010 Lords Chamber

Asked By

[Lord Touhig]

To ask Her Majesty’s Government whether the forthcoming Autism Act 2009 statutory guidance will be effective in delivering the vision set out in the strategy document Implementing “Fulfilling and Rewarding Lives”.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, yes, I believe that the planning guidance will be effective in delivering the strategy for adults with autism. This guidance has been developed with advice from health and social care professionals, people with autism and their carers and the voluntary groups representing them. Only by such a transparent, mutual approach can we achieve the vision that the Government have set out for adults with autism: fulfilling and rewarding lives within a society that accepts and understands them.

[Lord Touhig]

I thank the Minister for that reply. I am sure he agrees that, when planning services, it is important to know what services are needed and how many people need them. I do not know whether the Minister is aware of the National Audit Office report which has revealed that 80 per cent of councils have no idea how many people with autistic spectrum disorders live in their areas. Will the Minister therefore agree to meet our colleague, the noble Baroness, Lady Browning, myself and members of the National Autistic Society to discuss ways in which we can ensure that local authorities meet their statutory duties towards people with autism?

[Earl Howe]

My Lords, I should be very happy to meet the noble Lord to discuss those issues. Although we do not have definitive figures for the number of people with autism in England, we have commissioned a study into the prevalence of autism among adults to inform strategic planning at central and local levels to benefit adults with autism as they access public services. We have commissioned that study from the University of Leicester and it is due to report by March 2011.

Disabled People: Dementia

Lord Touhig Excerpts

Monday 11th October 2010 Lords Chamber

[Earl Howe]

My Lords, the noble Baroness is right. The national dementia strategy quite rightly recognises the need to improve the quality of care for people with dementia in hospital and that is identified in the new implementation plan as one of the key priorities for action. Of course, the main priority has to be to avoid admitting dementia patients to hospital in the first place, if possible. We should admit them only when it is strictly necessary and we should discharge them at the earliest opportunity. We have set priority areas for all hospitals to take urgent action, including appointing a senior member of staff to improve the quality of care for people with dementia and to look after the training of staff in hospitals.

[Lord Touhig]

My Lords, between a half and two-thirds of people with dementia never receive a formal diagnosis. That could be improved if GP practices, the mental health services and the royal colleges were to develop dementia care pathways. That was a recommendation by the Public Accounts Committee in the other place in 2008. What progress has been made in developing those pathways?

[Earl Howe]

My Lords, progress is being made thanks to the quality standard published by NICE in the summer on dementia care. That will underpin the outcomes framework that we shall look for in the care of dementia patients. He is absolutely right in what he says: two-thirds of people with dementia never receive a diagnosis in the first place; the UK is in the bottom third of countries in Europe for diagnosis and treatment of dementia patients; and GPs do not feel adequately trained in this area. So there is a lot of work to do.