Care Bill [HL]
Lord Turnberg Excerpts(11 years ago)
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Lord Ribeiro
My Lords, following the disruption of medical education that followed on from the MTAS debacle in 2007, one of the outcomes, which was a positive one, was the development of schools of surgery—a concept that we took on from the anaesthetists. This required personnel from the Royal College of Surgeons and the deaneries to take responsibility for the delivery and planning of training and education. However, this was very much confined to trainees. There was no requirement to extend it to consultants in terms of CPD.
However, we all know that health education does not end with certification; it is a continuum that occurs throughout one’s career as a professional doctor. It is a requirement to keep up to date. It is a requirement by the GMC to ensure that one knows what is happening within the wider medical field. One of the problems for doctors is having the time to go away and attend courses to improve one’s CPD. The amendment of the noble Lord, Lord Patel, places an obligation on HEE and the LETBs to support CPD and, in doing so, to allow the release of NHS staff, as he quite rightly said, to attend courses and educational programmes. It is also important to provide consultants and medical personnel of all disciplines with the opportunity to work in the wider NHS. It has been one of the basic tenets of the NHS that contributions in the wider NHS benefit not only the NHS but the participants, who learn a lot more about its workings. That, too, can improve and enhance one’s continuing development.
In that context, I welcome the suggestion made today several times by speakers—certainly by the noble Lord, Lord Hunt of Kings Heath, in that he made reference to the Francis report. One thing that came out of the Francis report was a clear statement that he would recommend that the GMC and the royal colleges work together in providing visits to educational centres. That was stopped some time ago. I think that there is a real opportunity to reintroduce that and I hope that the Minister, in responding, will address that issue. Here again is an opportunity, because in the past lessons were learnt by consultants visiting hospitals and looking at the education provision.
The very presence of peer groups in a hospital often helps to raise standards. Therefore, not only would CPD provide another training opportunity for those who participate but it would improve local education provision. The quality assurance of the training it would provide would ensure that, in the long term, patients benefited from such visits. For that, if nothing else, I support the amendment of the noble Lord, Lord Patel. We need to include something on continuing professional development because the whole emphasis of HEE is very much on training and trainees and it has very little to do with those who continue right through to retirement.
Lord Turnberg
My Lords, I, too, strongly support the amendment of the noble Lord, Lord Patel. Like him, I am concerned and rather surprised that there is no mention in the Bill about the need for trusts and other providers to support their staff in continuing professional development. We really cannot afford to have any staff working in front-line clinical services not keeping up to date when we know that clinical practice changes rapidly from month to month.
New tests, new diagnostic methods and new treatments are coming along fast and furious. Unless members of staff are given the time and facilities to keep abreast of all of those, we will get poorer and more out-of-date care. As the noble Lord, Lord Patel, said, it is unfortunately the case that when health budgets are stretched, as they almost always are, CPD budgets are the first to go. Time off to attend courses or to engage in appraisals disappears quickly, as everyone in the service is rushed off their feet.
It is in just those circumstances that a stand should be made. The amendment of the noble Lord, Lord Patel, makes it clear that the LETBs must include the need for employers to allow the time for CPD development of their staff. How else will doctors, for example, be able to comply with the mandatory requirement of the GMC to revalidate at regular intervals? We have struggled both long and hard to get revalidation mandated and we cannot afford to see it eroded now at the same time as the responsibility for funding CPD is falling to employers. LETBs must be given the teeth to insist that time and support for CPD are included in their educational contracts with trusts.
Baroness Emerton
My Lords, I support the amendment but I also support what the noble Lord, Lord Patel, said, about CPD being extended to other healthcare professionals. One thing that has emerged as a barometer from the questionnaires is that, often, the culture of an organisation is affected by the fact that there has been no appraisal system and no continuing professional education built into the programme for other healthcare professionals—nurses, physiotherapists and radiographers. There is an important issue here: all staff delivering care need to have regular appraisals and regular updating of their continuing professional education.
Lord Turnberg
I am sorry to interrupt again. I think the noble Earl said that we should leave it to the local providers to decide what or how much CPD individuals should have. We know, however, that at the moment local providers are very variable in how far they are willing to go along that route. The problem is that leaving it where it is certainly does not give any great confidence that CPD will be uniformly available in the service. Hence the amendment of the noble Lord, Lord Patel, which tries to give a little force and pressure to local providers so that they could indeed be sure that CPD was being provided. The noble Earl is full of good intentions, quite rightly, but we need a little more than that.
Earl Howe
I probably expressed the position less than well because I was seeking to indicate that CPD is inescapable. There are a whole host of reasons why providers and the LETBs cannot avoid a focus on continuing professional development. Equally, we do not want to prescribe any kind of ring-fenced budget for CPD, for the reasons we debated earlier: we are clear that we must leave it to LETBs to exercise autonomy in the way that they work out their local education and training plans. They will have to prioritise, inevitably, in certain cases and from year to year. It may be that they will have to make hard choices. The great thing about Health Education England is that, as a non-departmental public body separate from NHS England, it will have a dedicated budget which cannot be eroded by those who might wish to siphon money off to patient care, for example. I hope that, in that sense, the noble Lord, Lord Turnberg, can take some comfort. We are very clear that the prescription is there and that local providers cannot avoid addressing the needs of their employees for CPD, but at the same time we do not want to dictate to them how much to spend on this in any one year.
Lord Warner
My Lords, I suspect that the amendment has a similar purpose to Amendment 63, in the names of the noble Lords, Lord Turnberg and Lord Patel. The purpose is to ensure that in exercising its functions the HRA not only promotes the interests of research participants and those of the wider public in facilitating research but, in doing so, has to ensure that the publication of research findings takes place fairly and frankly. I tabled the amendment because there was concern in the Joint Select Committee, of which I was a member, about whether those responsible for conducting research were tempted on occasion to shield from public view the downside findings of a piece of research, for commercial or even professional, reputational reasons.
The Joint Committee’s discussions of that issue are set out in paragraphs 328 to 336 of its report to the Government. There was a lot of support in principle for greater transparency around research findings, and particularly clinical trials data, but there was some ambivalence in the discussions of witnesses in front of us, including the Minister, about prescribing this requirement in primary legislation. Tucked away in the discussion was a concern that this kind of approach would cause pharmaceutical companies to take clinical trials away from the UK. That was the implication, I think, of some of the remarks passed to the Joint Committee, which rightly in my view took a more robust view. In paragraph 335 of its report, it recommended that the Bill should be amended,
“so that promoting transparency in research and ensuring full publication of the results of research, consistently with preservation of patient confidentiality, becomes a statutory objective of the HRA”.
That is what my amendment aims to do.
My views on this issue have been shaped over time, but particularly by my experience as the Department of Health Minister responsible for the pharmaceutical industry and its regulation as well as for NHS R&D. In those roles, I did my bit to promote that industry and secure UK jobs in it, and I know the arguments about securing clinical trials. However, they have to be balanced with other considerations, when deliberate concealment of adverse research data has taken place. This is in nobody’s interests, including those of the company where it has taken place, because eventually it usually gets found out.
To illustrate my concerns, I want to detain the House a little longer with a brief account of what came up in my time as a Minister, when there was concealment. “Panorama” revealed, in 2003, what was happening with an anti-depressant called Seroxat, which was being given to about half a million people a year. Some of the people taking higher doses of the drug experienced suicidal feelings, and there were a number of cases of younger patients committing suicide. There was widespread concern among patient groups, and the MHRA had to launch a review, which included a small subset of younger patients under 18, for whom Seroxat was not licensed but for whom it was being prescribed by doctors. At that time, about 8,000 young people a year were being prescribed this drug, and the Committee on Safety of Medicines advised me that children taking this drug were more likely to self-harm or have suicidal thoughts. That finding was not then available to the regulators, but the public fuss caused by the media caused the company—and I want to mention it; it was GSK—to end up passing the information in its files to the regulators in the UK, Europe and the US. I took the view, in 2004, that there was a respectable case for prosecuting GSK, because it had failed to inform the MHRA in a timely fashion of the information on adverse reactions in juveniles.
The whole affair limped on after my time as a Minister and became the largest investigation of its kind. Over 1 million pages of evidence were scrutinised, with GSK challenging matters all the way. Matters were only concluded in March 2008 when the decision was taken not to prosecute GSK, which received a slap on the wrist. The then MHRA chief executive said in a press release:
“I remain concerned that GSK could and should have reported this information earlier than they did”.
This case—and there are others which I know of—illustrates why we should put in the Bill a clear requirement that research information is put into the public arena in a timely way when there is a downside as well as when there is an upside so that people can have a fuller picture of what is actually going on. If noble Lords want a fuller account of the Seroxat saga, they can find it in my book, A Suitable Case for Treatment, which is available in the Library. I beg to move.
Lord Turnberg
My Lords, the point of Amendment 63, which is in my name, is the need for the HRA to emphasise transparency in the reporting of clinical trials because patients and the public must have confidence that research in which they have been involved will be used in the best way to spread the message for the good of other sufferers. They have to know that results, whether negative or positive, are published. As my noble friend Lord Warner has said, it is particularly important if they are negative, for at least two reasons. First, it is to stop the unnecessary, wasteful repetition of the research by others who are unaware that it has already been done. Equally important is to prevent a bias in reports towards research that shows only that a new drug works when other, unpublished, research shows that it does not. This is particularly important when we consider what is called meta-analysis, whereby an analysis is made of all relevant published reports, brought together to provide a large database on whether a drug works or does not. If only the positive results are reported, we have a biased result at the end, which could result in all sorts of problems.
Open access to research data provides researchers with a much better picture of their field than if research results are held too closely to the chest, perhaps by researchers jealous of their findings or by drug companies fearful of rivals gaining an advantage. It is heartening to know that GSK seems to have learnt the lesson: it is the first pharmaceutical company to lead the way in transparency. Members of the Association of Medical Research Charities make it a condition of their grants that results are published. We are pushing on an open door and we just need the HRA to have some capacity to ensure transparency in NHS research.
Baroness Wheeler
My Lords, I support Amendments 58 and 63. It is right for my noble friends Lord Warner and Lord Turnberg and the noble Lord, Lord Patel, to press the Government on this important issue. As we have heard, the Joint Committee proposed including the promotion of transparency in research and ensuring full publication of the results of research—consistent with the preservation of patient confidentiality—in the Bill and we strongly support this.
This is our first opportunity to welcome the establishment of the Health Research Authority as a statutory body and we do so wholeheartedly. We recognise the vital importance of research and innovation to the NHS, the very real progress that is being made in these areas and the scale and pace of change in medical science. The HRA’s objectives not only promote and protect the interests of patients and the public in health and social care research but ensure that it is ethical and safe research, which inspires the public confidence that my noble friend Lord Turnberg spoke about.
Alongside other bodies, the HRA has a key role in promoting transparency, and we acknowledge that its recent guidance on how it will undertake this role sets out important measures that will go some way towards underlining that it takes its duty seriously. These include: gaining approval from research ethics committees before clinical trials can go ahead; a new timescale for registrations; the commitment to work with research funders and sponsors to set the standards for the publication and dissemination of research outcomes; taking steps to facilitate further analysis of detailed data; and plans to look at how patient consent forms can be amended to provide early consent and understanding on how data will be used, as well as how the HRA will be informed of the outcome of study findings.
There is no doubt that the HRA is committed to working with others to overcome barriers to transparency and create a culture of openness. The amendment and Amendment 63, which provide for the publication of research findings “fairly and frankly” and transparency in the reporting of clinical trials, would enshrine the HRA’s commitment in statute, and ensure that clinical research benefits patients and that the findings are available for others to learn and benefit from. As we have heard from my noble friend Lord Turnberg, the advice of the Association of Medical Research Charities to its members to ensure that there is a requirement to publish in the terms and conditions of all their research awards has played an important role in providing greater transparency and would be reinforced by greater HRA authority in this matter.
Finally, like other noble Lords, I received a valuable briefing from the National Advisory Council to the Thalidomide Trust on the need for transparency and a change in the law for the disclosure of clinical and healthy volunteer trial data in relation to the drugs available on the market. The briefing states:
“Adverse effects caused by drugs that are designed to lead to a health improvement can be difficult to prove, and easy for the pharmaceutical companies to dismiss ... At the core of the problem is the fact that the safety assessments of a drug, undertaken in clinical trials done prior to the drug’s launch, remain hidden once the drug is on the market. A patient experiencing adverse effects therefore has no access to data that could be used to prove their claim … the onus is on patients to prove it was a drug that harmed them rather than the company that already holds that evidence”.
The Thalidomide Trust proposes changes to the informed consent form to allow sharing of anonymised data and making data from clinical trials available and accessible to the public once a drug has been released on the market. The trust acknowledges that this is a difficult issue. Have the Government had any discussions with the trust on this matter? I should be grateful if the noble Earl would comment on this, either today or in a written response.
Health: Degenerative Brain Diseases
Lord Turnberg Excerpts(11 years ago)
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Earl Howe
My Lords, I am aware that NICE co-operates with its counterpart bodies not only in Europe but in other parts of the world; its work has an international dimension. As the same time, I say to my noble friend that NICE is seen as a world leader in its field. Many other countries look to NICE for the methodology that it adopts.
Lord Turnberg
I am sure that the noble Earl is aware that Alzheimer’s disease is increasing in frequency as we all age, and is becoming a severe health problem. The Alzheimer’s disease association is certainly anxious for brains to be put into its bank, because it seems that there is the potential for a cure for this disease in a few years’ time. I suspect that the noble Earl is aware that the research that is done on these brains will be extremely helpful in that respect.
Earl Howe
My Lords, I absolutely agree with the noble Lord, Lord Turnberg. Dementia is of course a particular focus for research using brain tissue. Also, there are many other neurodegenerative diseases, such as Parkinson’s, which could potentially benefit from this kind of research.
Care Bill [HL]
Lord Turnberg Excerpts(11 years ago)
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The Deputy Chairman of Committees (Viscount Ullswater)
My Lords, I must advise your Lordships that if this amendment is agreed, I will not be able to call Amendments 2 and 3 because of pre-emption.
Lord Turnberg
My Lords, I will speak to Amendment 2. Before I do so, I should explain that I have heard from the noble Lord, Lord Patel, who cannot be in this place this evening because of illness in the family. I strongly support the amendments of my noble friend Lord Hunt, in particular the idea of a nurse on the boards; I also very strongly support his ideas on trying to attract good managers to stay in the service for as long as possible.
Amendment 2 is the first of several amendments that I have tabled emphasising the need for Health Education England and the local education and training boards to pay particular attention to the maintenance of standards and quality in education and training. I express my interests here as someone who has spent many years trying to raise standards of medical education in my previous jobs as dean of a medical school, the president of the Royal College of Physicians and, perhaps of equal significance, as president of the Medical Protection Society, where I was brought face to face with what happens when standards fail or are allowed to slip.
This amendment specifically concerns the membership of Health Education England and the need for it to include at least one person with expertise in research and another in education and training. I will save my remarks on research until we debate later amendments, but so far as education and training are concerned, my fear is that in the drive to meet workforce requirements and staffing numbers we will lose out on standards and quality. This amendment simply makes more explicit the need for input on the board of someone who has particular expertise about education and training, and the maintenance of standards.
I will make another point now to save making it later. I believe that there is a conflict, not easy to resolve, between the desire to provide sufficient numbers of trained staff locally—as determined, quite rightly, by local providers—and the need to maintain national standards. For example, in medicine it is vital that a cardiologist, orthopaedic surgeon, general physician or trained nurse is trained to a national standard that is recognised everywhere. It is not acceptable for a local provider to decide what training should consist of, but they want someone whom they can rely on. It is vital that there are national standards and hence there is a need for someone at the Health Education England level who has the expertise to look at how those standards can be set.
So far as national workforce planning is concerned, I have lived through innumerable efforts at medical workforce planning and found them to be fraught with difficulty, largely because it takes so long to train doctors: five or six years as undergraduates, then another five or 10 years of specialist or general training. Predicting need for different types of doctors 10 or 15 years downstream is far from straightforward. The noble Earl kindly sent around a document on a mandate from the Government to Health Education England. However, I fear that the section entitled “Excellent Education”, with its emphasis on training multipotential individuals working in teams across all health sectors—important though that is—de-emphasises the need for specialists. That prospect fills me with apprehension—that five years downstream we will have a health service lacking essential parts. I fear that the right balance between the need for general across-sector care and specialist care may be tipping too far in these particular aspirations. In any event, for the moment, I will press for the placing of relevant education expertise on the board of HEE, as suggested in this amendment.
Lord Willis of Knaresborough
My Lords, in the Second Reading debate on the Health and Social Care Bill, now an Act, I made the point that while we were talking about structures until the cows came home, the things that really mattered were the education and training of the staff within the NHS and the research element that gave those staff the very best tools in order to be able to care for patients and have good patient outcomes.
I compliment not only my noble friend, but the whole House, and indeed the whole Parliament, on the way in which it got behind the proposal in that Bill which is now in this one to create Health Education England as a way forward. The appointment of Sir Keith Pearson, who knows the supply side very well and has the ability to bring people together to listen to what he has to say and to be able to develop Health Education England as a real force for good, is quite outstanding. My worry is that we will start to bind the hands of Sir Keith and Health Education England, and we must not do that. What is required now is an organisation that is given sufficient flexibility and power to be able to grasp the key issues that are facing the NHS and to move forward.
I support very strongly the amendment in the names of the noble Lords, Lord Turnberg and Lord Patel, to include on the board people with relevant expertise. I am pleased that the noble Lord did not go on to say exactly who should be on that board, because I believe that that would be a step too far. But to have somebody with a real background in training, education and medical research would bring great strengths to the board.
I also support Amendment 3 in the name of the noble Lord, Lord Hunt. Indeed, I support virtually all the amendments tabled by the noble Lord and compliment him on the way in which he introduced this part of the Bill. Having a registered nurse on the board is so important. If we do nothing else in terms of the Francis report, the one thing that shines through is that you need somebody within the organisation who brings to the board those issues of quality care at every level. That is really quite exciting. I hope that my noble friend will listen to the wise words of the noble Lord, Lord Hunt, and others, and ensure that nursing is given a real place at the table, because quite frankly for generations it has not been. Nurses are no longer the handmaidens and “handmasters” of other professionals. They are in fact equals.
Lord Turnberg
Lord Turnberg
I will not move this amendment but I want to make one brief comment. If we are to rely on the regulations to interpret what clinical expertise really means, it is unlikely, however, that expertise in education and training will not be essential. I hope that comment will be borne in mind.
Care Bill [HL]
Lord Turnberg Excerpts(11 years ago)
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Lord Turnberg
“( ) HEE should seek the advice of those bodies concerned with setting standards for education and training, including the regulatory bodies and Royal Colleges.”
Lord Turnberg
My Lords, my name is attached to three amendments in this group, Amendments 9, 18 and 34. In this group of amendments I have tried to go a little further with my general theme of improving quality and standards.
Amendment 9 refers to the functions of Health Education England in Schedule 5, under which it will seek advice from relevant bodies. Amendment 18 refers to quality, improvement in education and training and the need for HEE to co-operate with relevant bodies. Amendment 34 refers specifically to those from whom HEE should seek advice. In each of those amendments, I am anxious that due weight is given to advice and co-operation with those whose sole reason for existence is to ensure high standards of education and training—the General Medical Council, the General Dental Council, the Nursing and Midwifery Council and the royal colleges. Those colleges, after all, set the curricula for all medical and nursing trainees and arrange all the exams and assessments.
For Health Education England not to have access to all that expertise, and potentially even to ignore it, seems to me unhelpful. Some indication about that is needed in the Bill. Therefore, I have included specific mention of those bodies here.
Lord Turnberg
I am extremely grateful to the noble Earl for his very full reply, and for drawing attention to the meaning of Clause 89, which I now understand more fully. In view of that, I beg leave to withdraw the amendment.
Care Bill [HL]
Lord Turnberg Excerpts(11 years, 1 month ago)
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Lord Turnberg
My Lords, when I spoke in the debate on the Queen’s Speech last week I concentrated on care of the elderly in the community which is one of the most critical issues facing society, as we have heard from some remarkable speeches today. If anyone has any doubt about the scale of the problem they will just have to read Hansard. I will not repeat what I said the other day, save to reiterate my specific plea that we pay attention to the screening of vulnerable elderly people in the community by primary care and social services staff so that we can introduce simple preventive measures to keep people at home. I hope the noble Earl might say something about that.
Tonight I want to concentrate on the proposals in the Bill to establish Health Education England and the Health Research Authority as non-departmental public bodies. These are, of course, extremely welcome proposals but inevitably there are a number of aspects where we need to seek clarification and improvement. The roles of the HEE and the associated local education and training boards—inelegantly abbreviated as LETBs—are spelt out in the Explanatory Notes but I fear that the Bill itself is fairly silent on how it will ensure high quality and standards in education.
For example, much is made of the fact that the LETBs are provider-led and dominated by the needs of NHS trusts for sufficient numbers and range in the workforce to meet those needs. So far so good, but what is missing is a proper recognition that the quality of training, the curricular content and the skills and knowledge of those going through training programmes will be taken care of. Where, for instance, is reference made to the need to include postgraduate deans on the boards of LETBs? It is not in the Bill and given only passing reference in the Explanatory Notes. Where is reference to the need to engage closely with local universities or training colleges—that is, with those whose whole raison d’être is education and all that that entails? Content of training programmes and maintenance of standards is their special expertise and for providers to ignore that aspect will be to their detriment. I am sure they are aware of that but we need mention in the Bill of a need to involve universities, either in the membership of the board, albeit in a minority, or, if not that, then an obligation to seek their advice in formulating their programmes of training.
At the national level, in the HEE, there is some recognition in the notes to the Bill, but not in the Bill itself, of a need to seek advice from the royal colleges—here I have to express my interest as an ex-president of a royal college—the GMC, the GDC and the NMC in developing its policy. It seems to me that all those bodies have considerable expertise in education and training. Indeed, the main functions of the medical royal colleges, for example, are in the development of all the curricula for medical trainees and in setting their exams and assessments to make sure that they have reached an acceptable level of skills, aptitudes and knowledge. Every cardiologist, orthopaedic surgeon and psychiatrist has to go through a training programme devised and run by a royal college. The regulatory bodies have responsibilities for the oversight of training and education to ensure that it is fit for purpose. Yet despite all this remarkable body of expertise, no mention is to be found in the Bill that the HEE will draw on any of this for advice and assistance.
Then there is a further issue of the need to take account of the importance of clinical researchers in programmes of training and education. We have heard much helpful comment from Ministers about the need to embed research in the NHS and to make every health professional a researcher and every patient a willing participant. The noble Earl was extremely helpful in getting research high up the agenda for the NHS in the Health and Social Care Bill. It is, of course, through research that we may in due course find some answers to the major diseases from which we suffer such as dementia, diabetes and Parkinson’s, so it is vital that research really is in the middle of the NHS.
While the new Bill is very helpful in stating that the HEE must promote research into matters relating to its activities, which is rather subtle, it hardly takes account of the need for LETBs to take account of this in their training programmes. Those embarking on a clinical academic career have to be able to take time out from their purely clinical training to train in research, perhaps for up to three years if they are going to do a PhD. All other trainees, at least in medicine, need to be able to carry out some research so they have experience of what research is about. They are then in a better place to take advantage of the results of research and not resist the rapid introduction of innovations when they go on into practice. I fear that the dominance of provider-led interests in LETBs will lead them to paying little attention to this aspect of training unless they have access to advice from their local universities and the research community. I fear very much that the shadow body of the HEE has shown little sign so far that it is aware of this particular point.
I come now to the Health Research Authority. I believe we are extremely fortunate in having Professor Jonathan Montgomery as its first chairman. He is clearly switched on to the need to be able to protect the public and the patient interest, while at the same time encouraging high-quality clinical research and not putting unnecessarily burdensome regulation in the way. It might be thought that these twin responsibilities—the need to protect patients and ensure their safety and confidentiality on the one hand while promoting and encouraging research on the other—are opposed to each other but they are closely aligned. Patients want not only to be safe but they are very keen for research to be done on their diseases. Furthermore, surveys of patients’ attitudes show that more than 90% of patients want to be involved in research themselves in clinical trials. They are desperate for innovations in treatments arising from research to be applied to them. Of course they want to be safe and protected but they also want high-quality research, so the two go hand in hand. It is pleasing to know that Professor Montgomery is well aware of this and the need for proportionality in regulation.
I welcome the clear statements in the Bill on this and in particular in Clause 98(3) where it is proposed that the HRA must promote standardisation of the regulation of research across England and ensure that such regulation is proportionate. It is clear, too, that for the HRA to gain credibility with the public and patients it cannot simply pontificate about safety from on high. It must actively communicate with the public and have processes in place for it to be able to listen to the views of the wider public. It needs access to the public view and should put in place mechanisms to achieve that.
I come now to another aspect of transparency. In addition to its own transparency, the HRA should also be encouraging transparency of researchers engaged in clinical trials in academe and industry and their results should be published as expeditiously as is reasonably possible. Results should become freely available, after careful checking for reliability, whether they are positive or negative. It is helpful to know that GSK is leading the way in industry by publishing its data more openly and others are beginning to follow. We do not want the HRA to be given too rigid a formula. That would be counterproductive, but we do want to be able to encourage and support the HRA in its efforts to use measured persuasion.
Finally, it is good to see in the Bill the confirmation that the HRA will continue its good work in co-ordinating the work of the ethics committees and in taking on the roles provided until now by the Secretary of State and what was PIAG in ensuring the safe use of patients’ data. It is gratifying to know, too, that the HRA is moving towards a single application process for entry into the jungle of research regulation. There remains at least one major barrier to research and that is the local R&D approvals that have to be given by each trust where clinical trials are being done. This is where we need a rational, proportionate and national system and if the HRA can incorporate trust R&D approval into that national scheme, the research community would heave an enormous sigh of relief.
I hope I have not given the impression that I am unhappy with this part of the Bill. I think the proposals to set up HEE and the HRA are extremely valuable but of course there is always room for some improvement.
National Health Service (Procurement, Patient Choice and Competition) (No. 2) Regulations 2013
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Lord Turnberg
I am delighted to be able to follow the noble Lord, Lord Owen. He puts his finger on it. It is hard not to think that we are coming up against some rather polarised views lying behind this debate about how far we can go with the use of private providers in the NHS. On the one hand there are those who believe that private providers will drive up quality and efficiency by the competition that they introduce, and on the other those who see private providers in it for the profit that they will make from the NHS.
Clearly I cannot go into this tonight but I want to say two things. First, we have an NHS for which everyone pays through tax for the common good and which distributes resources to those who need it so that society as a whole can benefit. By opening up the NHS to private companies we are increasingly using that taxed income to provide for, among other things, their profits. When we go down that route we have to be sure that we are getting something that is worth while for society and that we have the balance right. Secondly, I have the feeling that instead of the welfare state, to which we are all signed up, being regarded for the common good, it seems to be increasingly regarded, in some quarters at least, as a cost to society and an onerous subordinate to economic policy. This is not a debate for today, although we need to have that sort of debate. It does, however, colour my views about this contentious set of regulations.
According to the wording of Regulation 5, as we have heard, commissioners are legally obliged to go out to tender unless they are satisfied that services can be provided only by a single provider. Despite the reassurances by the Minister and his colleagues, the wording here is so unambiguous that a number of distinguished lawyers tell us that there is no way out of having to tender for everything else. The fact that the Government’s lawyers are able to come up with a different conclusion, as I am sure the Minister will tell us, suggests at least that there is room for confusion and for something that would have to be tested in the court, and no doubt the courts will pray in aid the EU competition law.
I am most concerned about the problems that this tendering process will cause, as are the many organisations that have written to us. For example, if we look at where the most severe difficulties lie in the health service and try to think what tendering from a variety of providers might do to resolve them, we come up against a major barrier. It is in the care of the elderly, of those with long-term multiple illnesses and of those with mental illnesses that we are clearly failing in the NHS. Yet those are the services that private providers as well as insurers are least likely to want to take on. They are much more interested in aspects of care that come in neat packages—short-term items such as cold-planned surgery or investigation that are readily costed and charged for. But these are the sorts of care that by and large the NHS is pretty good at. It is here where the cherries lie and which private providers will try to pick, leaving longer-term care for the less glamorous, chronically ill elderly and the mentally ill to the NHS. It is not a future that many in the NHS are likely to welcome.
This says nothing about the administrative costs of this tendering and contracting, which will not be trivial. It says nothing about the barriers that it will throw up to the integration of care across several disciplines, which is already quite difficult to achieve. Will multiple providers make it easier or more difficult for integration? I cannot see it.
For these and the many other reasons that other noble Lords have raised, these regulations are a distraction designed to maximise private sector involvement and leave far too little room for commissioners to be sensible and flexible in their approach. They should be removed entirely, and if that is not possible they should be reworded to make it absolutely clear to commissioners and everyone else that what Ministers are telling us is also written clearly on the tin.
Lord Howard of Lympne
My Lords, I declare my interest as chair of Help the Hospices, and in a moment or two I shall put the remarks of the noble Lord, Lord Owen, in context. However, I shall begin by correcting a report that appeared in the Financial Times last week, which said that Help the Hospices and other charities regard these regulations as a fresh attempt to privatise the National Health Service. I cannot speak for the other organisations, but that is not the way that we at Help the Hospices look upon these regulations.
The original regulations gave rise to considerable concerns, and I pay tribute to the Government for being prepared to listen, to think again and to revise the regulations. The revised regulations go some considerable way towards allaying those concerns. They do not go the whole way, and the noble Lord, Lord Owen, identified some of the concerns that remain, but we believe that those concerns can be met not by annulling these regulations as the noble Lord, Lord Hunt, seeks to do this evening, but by ensuring that the guidance which the Government intend to provide removes any ambiguity and removes the dangers to which the noble Lord, Lord Owen, referred.
The noble Lord and I have long experience in different contexts of the difficulty of covering every contingency in the wording of regulations, of getting the wording of regulations absolutely right and avoiding any degree of ambiguity. The previous speaker, the noble Lord, Lord Turnberg, recognised that the Government’s legal advice was such that the fears that have been expressed simply would not arise if these regulations were properly interpreted. Monitor, which is to give the guidance that we await on the way in which these regulations are to be interpreted and implemented, has a very important role in that respect and will consult before issuing that guidance. We at Help the Hospices intend to take full advantage of the opportunity which that consultation affords to ensure that Monitor gets the guidance right, removes any ambiguity and ensures that any lingering concerns that we may have do not turn into reality.
It is true that the changes that are taking place in the National Health Service in the way in which we provide health services in this country pose a certain danger to voluntary organisations such as the hospice movement, but not because the Government intend to do any damage to the hospice movement, as was made clear to me and some of my colleagues from Help the Hospices when we had a meeting with the Secretary of State very recently. The danger lies in the law of unintended consequences, so it is right that we should be vigilant to ensure that those unintended consequences do not damage hospices that do such wonderful work and provide such remarkable care to those who are near the end of their life and benefit from the care that hospices provide. I am satisfied that that danger in this context can be averted by sensible and proper guidance from Monitor, and I hope that at the end of this debate the Minister will give the House some assurances about the nature of that guidance which will put to rest any lingering concerns that might exist.
Health: Cancer Drugs Fund
Lord Turnberg Excerpts(11 years, 3 months ago)
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Earl Howe
My Lords, we consulted on our proposals for value-based pricing between December 2010 and March 2011, and as part of that process a number of patient organisations contributed their views, which were reflected in the Government’s response to the consultation, published in July 2011.
Lord Turnberg
My Lords, what will happen to the panels of cancer experts that gave such valuable advice to SHAs about which drugs should be provided?
NHS: Mid Staffordshire NHS Foundation Trust
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Lord Turnberg
My Lords, I, too, thank the noble Lord, Lord Patel, for introducing this debate with his usual panache.
As Roy Griffiths said in 1983, when he was looking to change the management structure of the NHS,
“if Florence Nightingale were carrying her lamp through the corridors of the NHS today she would almost certainly be searching for the people in charge”.
I think she would have been more concerned today about finding someone in charge of the care of the patients in the corridors of the Mid Staffs hospital. She would have been looking for anyone able to explain what had been happening to the patients for so long and would have found no one.
The Francis report outlines a huge number of recommendations that include changes in the culture and much about policing the service to detect poor behaviour, but to my mind, beefing up the complaints system, while very important, comes a bit too late. We need to think more about preventing the need for the complaints, and there is one crucial omission; while there is a strong focus on the responsibilities of the managers and the board, none of these people, try as they might, can be on the wards all the time, every day of the week. They visit from time to time. The doctors, too, come and go as they rush to their clinics or operating theatres. The people on the wards all the time are the nurses, and this is where we have to focus hard.
I am in no position to criticise the nurses themselves—they do a fantastic job, and I have personal reasons for being enormously grateful for what they do. My aim in pointing at the nurses is much more to do with the way in which nursing careers are organised. This is where I believe some changes are needed. We need to bring back the old-style career-grade sister who was in charge of the ward. Many years ago when I was a young doctor—I am sorry that I sound like an old fogey—the sister in charge really was in charge. She was usually a mature woman—there were few men in those roles—and she ran her ward with a rod of iron. Both the patients and the doctors ran scared and were loath to cross her, but she knew everything about every patient, and the doctors relied on her implicitly. She would not have countenanced the sorts of behaviour that were described so vividly in the Francis report.
What has happened to that post? Now the role of ward sister is not regarded as a career post at all. It is simply a rung on a ladder, and after a year or so they are promoted to teaching or more managerial roles. It is just a stepping stone to bigger and better things that are not so closely engaged with the patients.
Consultant friends tell me that it is unusual for them to find a nurse, let alone the sister, to accompany them on their ward rounds, or indeed to find anyone to tell them what has been happening to their patients. The solution, to my mind, is not the heavy hand of top-down monitoring and punitive complaints procedures, but the placing on each ward of sisters or charge nurses in clinical career posts—I stress clinical posts—who are given full responsibility for what goes on in their wards and are awarded accordingly. My view is that they should be given exactly the same salary as a consultant, since that would be commensurate with their level of responsibility. It would be a post that commands all the respect that you would expect of someone in such an important position. I recognise that this idea might not meet with the approval of the nursing professional bodies, but I ask the Minister to consider this proposal sympathetically. It seems to me to be the only way in which Florence Nightingale and her lamp may be able to find someone in charge of the patients’ well-being.
Health: Cardiology
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Earl Howe
My Lords, I pay tribute to the Oliver King Foundation for its work, as indeed I do to Cardiac Risk in the Young, which for many years has been campaigning very tellingly and successfully in this area. I think that my initial Answer should have satisfied my noble friend on the screening question, because that is now being reviewed by the screening committee. Regarding defibrillators, we have to look at the need to improve survival rates in the most effective way. I understand that the majority of these deaths—possibly as many as 80%—occur in the home. While we agree that the wider availability of defibrillators could save additional lives, CPR skills—cardiopulmonary resuscitation—should save more lives. To that end, the outcomes strategy says that my department will work with the Resuscitation Council, the British Heart Foundation and others to increase the number of people who are trained in CPR.
Lord Turnberg
My Lords, will the noble Earl encourage all schools to incorporate training in CPR for all schoolchildren? A skill learnt there will carry on through the rest of a child’s life.
Earl Howe
My Lords, the noble Lord makes a very good point. Again, as the CVD outcomes strategy sets out, basic life-support skills could be more widely taught as part of volunteering programmes; for example, in schools and the workplace. I am aware that bystander CPR doubles survival rates yet is attempted in only 20% to 30% of cases. There is scope for all emergency service personnel to be trained in CPR, and for basic life-support skills to be taught more widely.
Care Services: Elderly People
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Lord Turnberg
To ask Her Majesty’s Government what steps they are taking to improve care in the community for elderly patients.
Lord Turnberg
My Lords, I am grateful for the opportunity to open this debate, even though I suspect that many noble Lords might share a faint sense of déjà vu about this topic. However, the fact that care in the community keeps reappearing on our agenda suggests that, despite numerous impressive reports and repeated debates in this House, we are not yet anywhere near solving the problems.
I suspect that few here will admit to any ignorance of the facts, so I hope noble Lords will forgive me if I start by reiterating the nature of the difficulties we face. It may save others having to repeat them. First, the country has entered a prolonged period of severe economic constraint, so there is little new money available centrally. Secondly, we have no control over the demand for social care that is growing at a remarkable rate.
The population is ageing as life expectancy goes up in an inexorable straight line. The current 3 million people over the age of 65 will rise to almost 5 million in the next 20 years, while the number of over 85 year- olds will double from 1.3 million to 2.6 million. We would celebrate this extension of life were it not for the fact that the number with multiple chronic diseases will also increase by about a third, while the number of those with dementia is set to double from the current estimate of 800,000. If that is not enough to frighten you, there is the statistic that one in three people over the age of 85 will develop dementia. That is what I am told. Many of these people end up in an acute hospital, the place least suited to their needs, and the number lingering there unnecessarily is huge. Of the over 85 year-olds admitted, some 140,000 stay for more than 30 days, and the numbers are rising. A diagnosis of dementia is the primary reason for admission in some 55,000 patients a year, in the majority of whom the diagnosis had not been made before admission. Where, I wonder, were the GPs?
These patients are admitted, but too often there is nowhere else for them to go. Social services departments are sorely underfunded and about four-fifths of local authorities are now said to be restricting social care to those with needs graded as substantial or critical. There is a black hole of some £16.5 billion looming in social care funding over the next few years. The gap between the money needed to meet demands and that available is growing year by year. Here we have the nub of the problem—increasing demand from an ageing population acquiring multiple long-term illnesses and a veritable epidemic of dementia, together with social services departments stretched way beyond their capacity now and with a future in which they will be unable to deliver even the basics of care, and all against a background of severe constraints on the money available from government.
We cannot simply go on as we are and try to patch up the current system of an NHS designed for acute hospital care, essential though that may be, while the desperate need is for prevention and the long-term care of the elderly. We must start now to develop a long-term plan to meet these problems. My first question to the noble Earl is: is there any sign that the Government are thinking along the lines of long-term future planning?
At the end of the day, we must ask ourselves where the money is to come from. Of course, some measures could be taken that would help a little. The poor co-ordination between care workers in hospital and in the community has been resolved in a number of well recognised places around the country and more should be done to spread that good practice. Of course, there may be efficiency gains to be made somewhere in the system. Then there is the recent government initiative in the wake of the Dilnot report to help the elderly pay for their care. Will that ease the financial burden on local authorities? I fear not, because although it offers some help to the elderly themselves, it seems more likely to add to the problems of local authorities than to help them.
Then there are the usual calls for funds to be transferred from the supposedly cash-rich NHS to social services. I am very supportive of proposals that NHS and social service budgets should be pooled to fund care for the elderly. That makes a lot of sense and I was happy to see something along those lines in Andy Burnham’s recent speech about a future Labour health policy. We need to think, too, not only about merging budgets but also medical and nursing staff so that they can work across the boundaries between hospital and community. We also need to look critically at how we can incentivise and support GPs who are really the key players in the community. It is far from clear whether they are prepared in the CCGs for commissioning long-term care. Will the noble Earl tell us whether any attention is being focused on the role of GPs there?
What about closing hospitals or beds and transferring the savings? Data showing that up to a third of acute hospital beds are occupied by patients who should not be in hospital at all provide ammunition for those who see considerable savings from cutting bed numbers. That is not easy. If we try to go along that route, we have to look at where the costs of acute hospitals really lie. They lie largely in the staff and relatively less in the number of beds. The workload for the medical and nursing staff of acute hospitals is not determined by the number of beds, or even by the number of long-stay patients, but by the rising tide of acute emergency admissions. It is hard to escape the conclusion that we are not well off in NHS hospital services. Hardly a day goes by when we do not hear of failings in the care of the acutely ill.
If wards or even whole hospitals were to close, that acute workload would not diminish. Indeed, the more rapid throughput of patients through a smaller number of hospital beds would increase the intensity of the work. I am not saying that there would not be any savings made on, for example, heating and lighting bills and perhaps on administration, but the savings to be made, especially on doctors and nurses, would be rather less than one might hope. That may account for the intriguing piece of research evidence from Julien Forder, who published a paper in the Journal of Health Economics in 2009 in which he showed that for every pound spent on community services it was possible to save only a third of a pound on hospital services. Caring for someone in the community is not a cheap option.
Meanwhile the NHS itself is under remarkable cost-saving pressures as it seeks to answer the Nicholson challenge. Hospitals are barely coping in many instances, and the prospect of diverting even more funds is likely to be impossible to bear. I am not suggesting that rationalisation of services into a smaller number of specialised centres is not a good thing—it clearly is—but closing acute hospitals to save money simply to transfer it into the community does not bear too close examination. In any case, there are the calculations suggesting that there will be a shortfall in NHS funding of some £30 billion per annum by 2020 on current trends, so the question remains: where will the funds for social services come from? It is difficult to see much coming from simply integrating NHS and social service budgets, desirable though that may be. Simply pooling two inadequate sources of money does not sound like an answer to me. We have to face the idea that the Government of the day, whoever they are, will have to give a higher priority to care in the community than they have currently been able to do. It is a political decision, and we must think more broadly than simply within the box of the Department of Health.
Are there are any discussions going on between government departments— housing, transport and so on—on plans for future care in the community? How much priority are Governments as a whole willing to give to this compared, for example, with a high-speed train or nuclear submarine, desirable though some may think they are? Do they have a higher priority? These are decisions that only a Government have to face. I do not envy them for that, but in a democracy such as ours I do not believe it is entirely wishful thinking to feel that a clear majority of the population would strongly favour a diversion of resources to areas that they think are of high priority, and I can think of few higher priorities than the way we care for our elderly.