Health and Social Care Bill
Lord Turnberg Excerpts(12 years, 8 months ago)
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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.
NHS: Standards of Care and Commissioning
Lord Turnberg Excerpts(13 years, 2 months ago)
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Lord Turnberg
To call attention to standards of care and the commissioning of services in the National Health Service; and to move for papers.
Lord Turnberg
My Lords, I am delighted to have this opportunity of opening this debate. I am pleased that so many noble Lords are remaining in the Chamber and are going to contribute. I look forward to hearing what they have to say.
I shall focus my remarks on recent reports of failures in standards of care, particularly for the elderly, but this is also a good opportunity to examine whether the commissioning arrangements proposed in the new Bill will have a positive or a negative effect on standards of care. Perhaps, too, we should look at how the Bill might be used to make things better.
I am someone who has spent most of his life working in the NHS and I bow to no one in my support and admiration of what it achieves. I see enormous advances being made every year, and patients who would no doubt have died are now cured and surviving into old age. Medicine has been transformed out of all recognition during my working life.
It is because I have this pride and huge admiration of the NHS and the people who work in it that I now feel a deep sense of shame. Despite these wonderful advances, in too many places we have been ignoring the common decency needed to care for the vulnerable, the sick and the elderly—and it is the elderly who are often the most vulnerable. As Ann Abraham, the Health Service Ombudsman, said in her report, there is a,
“gulf between the principles and values of the NHS Constitution and the felt reality of being an older person in the care of the NHS in England”.
That is why I am going to focus on the elderly, but they are not the only group where standards have slipped. I suspect that other noble Lords may speak about the mentally ill, and only the other day we had a report about failures in maternity services.
Of course, the media are quick to pick up the seemingly occasional horror stories of neglect in a hospital. You might want to hide behind the idea that these are rare incidents against a background in which 1 million people are looked after perfectly well in our hospitals and nursing homes every 36 hours, and that is absolutely true. But it turns out that it is not a rare or unusual event. It seems to be happening far too often, and stories of neglect are just too common for comfort: patients, usually in a geriatric ward, unable to eat the food left out of reach at the end of the bed and collected by staff seemingly unaware that it has not been touched, and too busy to notice that a thirsty patient is unable to even drink without help—or, worse, too busy to notice that a helpless patient, unable to get out of bed and incontinent, is sitting in damp sheets for hours or, the final degradation, soiled by faeces and unwashed for days.
Noble Lords might ask whether I exaggerate. Where is the evidence that this picture is not just a rare, occasional lapse in an otherwise acceptable system of care? Well, quite apart from the rather common anecdotes of many with elderly relatives, there is now the report of the ombudsman in which she describes 10 examples of the complaints she receives that emphasise just how bad it can get.
We cannot say that we have not been warned. In 1997 we had the report from Age Concern in its “Dignity on the Ward” campaign, describing failing standards of care. When it followed that up 10 years later, in 2007, it found that little or nothing had changed. The Commission for Health Improvement in 2003, the Healthcare Commission in 2007 and the Care Quality Commission in 2010, despite regularly changing their names, came up with the same message. Now there is the book that has just been published, Michael Mandelstam’s How We Treat the Sick, which brings all this together in a devastating way.
The scandal at the Mid Staffordshire hospital of a year or so ago turns out not to be an isolated example. Every time we have a disastrous fall in standards we have another report or inquiry. I will not list all the hospitals or nursing homes that have been the subject of criticism but they range from Cornwall to Rotherham, from Tameside to Southampton and from Oxford to Bolton. There are just too many, and it is clearly not a new phenomenon. It went on under the past Government and the one before that, so I do not want to make any political points here. But how can we have tolerated this neglect of our most vulnerable citizens for so long? No one can afford to be sanguine—not the doctors, not the nurses, not the managers and not the Government. I want to say a few words about why and how this is happening and suggest what we might do about it, because we certainly cannot allow it to go on.
Let me apologise for starting with the nurses, for whom I have the greatest admiration and to whom I owe a great deal of personal gratitude. However, at the end of the day, it is the nurses who patients look to first for their personal care and empathy. It is always tempting to look back to a golden age that never was, but one thing that is clearly fixed in my mind is how high the standards of nursing care were on the medical wards where I worked in the 1950s and 1960s. Those were the days when the sister in charge of her ward really was in charge. She was usually a mature woman in a career job who made absolutely certain that everything ran efficiently and well. I admit to running scared of her; as, indeed, did the patients.
However, those were the days before the revolutions in nurse management and nursing education. One of the unintended consequences of the upward drive to better educated nurses with university degrees has been the development of a generation whose aspirations are set high. They quite reasonably expect to have a career in which they can practise their skills to a high standard. Who can blame them? They do a great job with all the caring attitudes you can wish for. However, that has left a gap at the more basic and, to many, less attractive level of the general and geriatric ward where there is greater emphasis on the basic needs of patients: feeding, washing, help with movement, going to the toilet and so on.
Those are the wards where staffing levels are often lower per patient in the belief that they do not need the more intensive, one-to-one care of the specialist units. So they are often understaffed and sometimes come to rely on temporary, or “bank”, staff, who constantly change. Continuity of care is damaged as patients, already a little disorientated by being removed from their familiar environment, are faced with a bewildering series of new faces.
It is not only the nurses who are constantly changing. Confusion is compounded by the way the rotas for the ward doctors are arranged to fit in with the European working time directive or as they rotate through yet another experience to chalk up on their training programme. So there are new faces at every turn. These wards do not have the champions that the specialised departments have, who can put pressure on management to protect them from cuts. Not much wonder that nurses in training pass through those experiences quickly on their way to higher things. Nursing sisters in charge may not stay long enough to be able to stamp their authority and, in any case, are distracted by paperwork or, nowadays, putting stuff into their computers—care plans and the like.
I fear that these changes have created a situation in which we have two starkly different standards of care. On the one hand we have highly trained, highly professional and caring nurses in well staffed specialised units—intensive care, coronary care, chemotherapy units and the like—and, on the other hand, poorly staffed wards, rushed nurses, falling morale, falling standards and poor supervision. These are the staff who are struggling to cope with patients whose vulnerability makes enormous demands for the care and attention that the nurses have neither the time nor the patience for.
Of course, this picture is not true everywhere and many, probably most, wards and hospitals are very good indeed. It is just that this picture is too common for us to take any comfort from it.
So what is to be done? Here it is clear that there is a need for a multifocused set of actions which no one profession or body can shirk. First, we must have someone at ward level who takes full responsibility for ensuring that patients are properly looked after with the respect and dignity that they deserve. That is absolutely key. I hope that my nursing friends will forgive me for saying that we should be making this job, the ward sister or charge nurse, a career post and rewarding those who do it accordingly.
Lord Turnberg
My Lords, there has to be some continuity in that post to make it an attractive alternative to the lofty pastures of the specialised departments.
Then there is the issue of too few carers on the wards. What happened to all those state-enrolled nurses—SENs—whose roles were predominantly in the caring world and who did not aspire to higher degrees? They disappeared in project 2000. Is it possible for us to resurrect the SEN grade and make it attractive again? I hope that some thought can be given to that.
That leads me to the medical profession, who cannot absolve themselves—ourselves—from responsibility for the neglect we are now discussing. They, after all, must see the way their patients are being cared for and, I am afraid, have not raised their voices loud enough. They should be leading the charge for proper staffing levels on their wards. They should be pressing hard on the managers of their hospitals. Of course, they really must do something about these disruptive rotas that are destroying the continuity of care that patients need and deserve.
The managers must make themselves much more aware of their responsibility to ensure that there are sufficient staff on these wards to cope with what is one of the most demanding areas of a hospital. They should know that these wards cannot be among the first, for example, to take cuts. Then there are the responsibilities of the trust boards. Board members have to be rather more hands-on and need to know what is going on in their wards. Many obviously do, but it seems that there are too many who do not.
Finally, I come to those bodies who will be commissioning services in the bright new tomorrow, the GP consortia, and the responsibilities that we should be placing on them for standards of care in the NHS, under the Health and Social Care Bill coming through the House—in whatever form that Bill survives. To paraphrase Aneurin Bevan, there are bed pans clanging on the floor all over the country and, in the rush to devolution to the local level, important though that is, devolved responsibility must also mean some central accountability.
As these services are commissioned, we must make sure that the Bill places a duty on the GP consortia to make sure that high standards of care for the elderly, at least, are a contractual obligation on the providers. Furthermore, we must have a robust system of monitoring so that we can have some confidence that this care is actually being provided. Perhaps the proposed commissioning board can take this on, but only if it has the capacity to monitor what is going on in hospitals and nursing homes, and has a mechanism for action when standards slip.
We have been through too many years in which we have seen indifference punctuated by intermittent reports and wringing of hands. It has to stop. The time for action is now.
Lord Turnberg
My Lords, this has been a fascinating debate and I am enormously grateful to noble Lords for many outstanding speeches. I have learnt a lot. I am only sorry that we had such a short time—each speaker had only four minutes—but I am constantly amazed at how noble Lords are able to pack in so much useful information in such a short time. The noble Earl, as one might expect, was eloquent and convincing, but it remains to be seen how many he has convinced around the House. I am sure that he is as aware as I am that these are not the last words we will hear on these matters. With those few comments, I beg leave to withdraw the Motion.
NHS: Front-line and Specialised Services
Lord Turnberg Excerpts(13 years, 5 months ago)
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Lord Turnberg
To ask Her Majesty’s Government what steps they are taking to ensure that the proposed changes to the National Health Service will not damage front-line and specialised services.
Lord Turnberg
My Lords, I suspect that your Lordships may feel that we have had rather a surfeit of debates on the NHS of late, and we have not even seen the Bill yet. However, I am pleased to open this debate as it gives us an opportunity to reflect on what the Minister has said in his previous responses and to try to be constructive in preparing for the Bill.
I should express my interests again as someone who has spent most of his working life in the NHS as a physician and professor of medicine and then as president of the Royal College of Physicians and more recently as scientific adviser to the Association of Medical Research Charities. I am pleased that the noble Baroness, Lady Jolly, will make her maiden speech in this debate. I very much look forward to hearing what she has to say.
In our previous debates a large number of criticisms of the White Paper came up, ranging from the wide extent of the proposed changes and whether they were proportionate to the perceived problems of an NHS of which many noble Lords extol the virtues, to a sense that a damaging commercialisation was creeping in. I have to admit that the previous Government were not immune from reorganisation and re-reorganisation zeal but it is significant that it was only when there was a clear increase in funding and a remarkable rise in the number of nurses and doctors that we saw a real improvement in patient care. So while reorganisations may be necessary at times, it is money that talks. At a time when we will be seeing retrenchment in the service, we must ensure that we do not cut these front-line staff.
I imagine that the Minister is aware of the study carried out by Sir Brian Jarman a few years ago in which he showed that there was a strong negative correlation between the number of doctors in a hospital and the mortality rate in that hospital—the more doctors, the lower the death rate. In that light, are there to be any cuts in the number of trainee doctors in the near future?
I shall mention three specific topics that impinge on front-line services: the pathfinder consortia; integrated services; and research and teaching. The pathfinders should generate a lot of valuable information. Leaving aside the bias that is introduced by the fact that this is a group of self-selecting enthusiasts who may not represent the generality of somewhat disinterested GPs, the data they will produce should be extremely helpful in deciding which paths to go down and which to avoid. After all, that is what I understand by the term “pathfinder”.
So my questions for the noble Earl are, first, will the Department of Health collect information that will help in the design and size of the generality of consortia when they are rolled out? Secondly, what sort of information will be used in this assessment? Will they be those easy to measure data such as waiting lists or waiting times which at best are relevant only to patients needing cold surgery, such as hip operations, but not relevant to the majority of patients you find in hospitals who are usually brought in as emergencies, such as those with heart attacks, strokes or collapses of various sorts? Or will they try to get information on outcomes that are more meaningful for patients, such as how well they were treated as individuals, how quickly they felt better and whether they got back to work, or whether smoking cessation measures have been more successful, how well alcohol reduction programmes are working and whether all these sorts of outcomes are better under the new arrangements? There is a very welcome emphasis on outcomes in the Government’s strategy for cancer, published yesterday. I ask the noble Earl whether a similar approach is intended for the many non-cancer patients faced by the consortia. Many of these outcomes need long-term study, but how else are we going to know whether we are doing any good by these changes? Will the department gather the type of information that can let us know which pathfinders to follow and which to avoid?
I return to the issue of integrated care that everyone—the royal colleges, the BMA, and the King’s Fund—see as the most effective way in which services should be designed and delivered. By integrated care, I mean integration not only across primary care and social services but right across the spectrum, from the community to the secondary care sector where so much of the costs are to be found. You have only to see an elderly patient lingering unnecessarily in an expensive and potentially dangerous hospital bed because of a lack of facilities in the community to recognise the importance of integration of care.
Problems are due not only to lack of facilities, but are equally likely to be due to poor communication between the two parts of what should be a seamless service. It is patients with complex, multiple diseases who form the majority and need seamless, joined-up, care across all three sectors. There are plenty of excellent guidelines to best practice for all these types of patients. The guidelines come from the royal colleges, specialist societies, medical research charities and a variety of other organisations. These guidelines are ripe for adoption by consortia for their contracts. One of the problems in the current NHS has been the slow take-up and implementation of good practice guidance. An obvious example is the national service framework for the care of stroke patients, published a decade ago and not yet fully implemented everywhere. What efforts will be made to encourage the spread of good practice, and how will that be incorporated into contracts by consortia? How will consortia use the expertise and knowledge of clinicians in secondary care and of front-line staff in the community sector? They should be working closely together. How will they overcome the potential barriers to this type of collaboration by the competitive environment and the “any willing provider” concept?
I want to say something about localism and its impact on research. In previous debates, the Minister was reassuringly clear about his commitment to research in the NHS, and the relative protection of the NHS research budget is of course very welcome. I congratulate the noble Earl and Dame Sally Davies on their efforts in achieving this. In this respect, what is to happen to OSCHR, the Office for Strategic Co-ordination of Health Research, the body set up to help co-ordinate research funding between the MRC and the NHS?
My main concern here is the role of GPs and the consortia in commissioning research and teaching. A recent survey by the Association of Medical Research Charities and Involve found that the vast majority of patients were happy to give consent for the use of their personal data for research, but that few GPs were interested in research, and that even the fairly straightforward business of seeking consent from patients was regarded by many as difficult and too time consuming. Therefore, if GPs are to have a key role in NHS research, it will be vital to give them some sort of incentive for their involvement. I should be very interested in hearing more from the noble Earl about how he thinks we might provide this stimulus.
Finally on research, I expect that the Minister will have seen the excellent recent report from the Academy of Medical Sciences, commissioned by his department, on the regulation of research. Is it his expectation that the Government will accept the recommendations in the report, particularly those relevant to streamlining regulation?
I hope I have been a little more constructive today and I look forward to the contributions of other noble Lords and, of course, to the response from the noble Earl.
NHS: Reorganisation
Lord Turnberg Excerpts(13 years, 6 months ago)
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Lord Turnberg
My Lords, I, too, congratulate my noble friend Lord Touhig on introducing the debate at such a cleverly opportune moment.
As a physician who has spent most of his life working, in one guise or another, within the NHS, I have always thought it self-evident that patients have to be right at the centre of the health service and that much greater responsibility for providing that service should be devolved to the professionals in the field. So I cannot fault the Government’s aspirations. However, when we consider how these aims are to be achieved, we run into formidable difficulties and I cannot help but feel apprehensive.
It is with the roles and responsibilities of the GP consortia, which will play a pivotal role in the Government’s plans, that I have most concerns. These concerns are largely shared now by the Royal College of General Practitioners. First, there is a suggestion that there will be 500 consortia. Is that so? If it is, we will have a range of problems. Where will they all get the expertise in managing the contracting for services? We have enough problems with the variability between PCTs in commissioning—some are good and some are poor—and so 500 will be very difficult. Then there is the problem of the extra cost of all the staff and infrastructure needed to run 500 new organisations. I ask the noble Earl: how many do the Government imagine we will need?
On contracting for uncommon or unusual diseases, it is proposed that larger groupings of consortia will be formed to gather together the relevant specialist expertise. So we will then have at least three tiers of commissioning organisations—consortia, super consortia and the commissioning board. This system is ripe for confusion, overlap and a potential for competition between commissioners, to say nothing of the difficulties of hospital trusts faced with a confusing array of contractors. We know from experience with GP fundholding that the kind of arrangement where groups of fundholders are supposed to join forces just does not work.
Of course, it is valuable to devolve responsibility to the local level but we cannot ignore the likely effect of this on the variability of the services provided in, presumably, 500 or so different areas of the country. Is the postcode lottery likely to be made better or worse in such a system? What safeguards will be put in place that will ensure that patients of one consortium do not complain that they are getting lesser treatment than their neighbours? I know that the Minister takes these matters very seriously. I will in a moment make some suggestions that might help him overcome some of the problems.
GPs will now have financial responsibility for the care of their patients. Two tensions will arise. First, GPs will make decisions about what care the patient sitting in front of them in their surgery should or should not have. If they feel that they cannot afford a particular treatment, it is a recipe for a loss of trust by the patient in their doctor. GPs will have that responsibility. Let us remember that they will no longer have the back-up of NICE to take these difficult decisions off their shoulders. The doctor/patient relationship is threatened when doctors are seen to be the agents of rationing on behalf of the NHS. It could, for example, tempt GPs into trying to tailor their list of patients to those with the least demanding diseases.
The second tension will arise from the patient being able to choose from “any willing provider”, as the White Paper puts it. Quite apart from the conflict that could arise between the GP trying to balance the books on the one hand and the patient demanding some expensive treatment on the other, there is the whole question of whether this combination of choice and willing providers conflicts with the efficiency with which the service can run and the equity of access that we all cherish so deeply. I do not think that this issue has been given sufficient attention in the rush to push the changes through.
It is not much wonder that GPs are worried and that the Royal College of General Practitioners has voiced clear concerns. They are worried about the financial risks that will be placed on their shoulders, about their lack of expertise in the new skills that will be expected of them and about the threats to the doctor, patient relationship.
Noble Lords have mentioned integrated care. There seems little doubt that the best way for patients to have access to a safe, effective and efficient service is through those in primary, secondary and social services working closely together both in designing care pathways and delivering the care. In the words of the college of GPs, this is the essential cornerstone of an effective healthcare system.
When I brought this up in our debate on 28 October, the noble Earl expressed his strong support for the concept, but there is unfortunately little information around as to how it might be put into practice. Indeed, the competitive environment gives little encouragement that integrated care will be given more than lip service. So I ask again whether the Minister has any information on how integrated care might be put into practice.
Perhaps I may make three proposals that might help ease some of these difficulties. First, the number of consortia should be kept low—probably no more than 20 to 50. This will keep the costs down, allow specialist expertise in management and contracting to be equally available to them, reduce the number of confusing tiers of commissioning bodies and take a burdensome load off the many reluctant GPs. It will be interesting to hear about the experience of the pathfinder consortia. Clearly they are the keen minority, but I suspect that they would welcome such a proposal.
Secondly, I respectfully suggest that we keep the roles and responsibilities of NICE as they are and do not change them at all, at least until we can see how GPs get on with their new responsibilities. Thirdly and finally, can we see whether it is possible to develop a proper system of commissioning that incorporates the concepts of integrated care?
Department of Health: Arm’s-length Bodies
Lord Turnberg Excerpts(13 years, 7 months ago)
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Earl Howe
They are different skill sets, but I am not aware that Parliament has visited these issues, let alone revisited them. As I said, we will have the opportunity to do that, but the proposals we have outlined will ensure that the teams that are currently involved in inspection activities will be kept together. I see no reason why they should not be.
Lord Turnberg
My Lords, perhaps I may ask the noble Earl about the Health Protection Agency. What advantages does he expect to come out of moving the HPA into the Department of Health?
Mental Health
Lord Turnberg Excerpts(13 years, 7 months ago)
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Earl Howe
My Lords, my noble friend is absolutely right: this is a cross-government effort. It is not simply for the Department of Health to deal with the issue because just about every department has some sort of remit in this area. I would say that, in particular on the attainment of children at school, we will focus very much on children from disadvantaged backgrounds because there is a high correlation between mental ill health and poverty, and mental ill health and deprivation. That will be a major focus.
Lord Turnberg
My Lords, what steps are the Government taking to ensure that GP consortia have access to the expert advice they will need if they are to commission positive mental health messages and the prevention of mental illness?
Earl Howe
My Lords, many GPs understand the issues very well and are keen to get on with the agenda. Our proposed model of GP commissioning means that practices will have flexibility within the new legislative framework to form consortia in ways designed to secure the best healthcare and outcomes for their patients. That will include mental health and could involve, for example, taking commissioning decisions collectively with perhaps a lead consortium for mental health.
Health: Chronic Fatigue Syndrome
Lord Turnberg Excerpts(13 years, 7 months ago)
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Lord Turnberg
My Lords, is it not the case that we have not been able to discover the cause of this very unpleasant disease so far and we have no real effective treatments? While we are waiting for both of those, the best form of management seems to be cognitive behavioural therapy. Does he agree?
Earl Howe
My Lords, cognitive behavioural therapy is indeed part of the NICE recommendations, but only a part in so far as it is appropriate for any chronic condition to have such therapy. I am sure that the noble Lord agrees that the NICE guidance recognised a clinical and physical basis to this condition as well. Therefore, a multifactorial approach is appropriate.
Health: NICE
Lord Turnberg Excerpts(13 years, 7 months ago)
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Lord Turnberg
Does the Minister agree that to devolve responsibility for prescribing expensive drugs to GPs faces them with a very difficult ethical dilemma? Should they prescribe a very expensive drug, costing thousands of pounds, with only marginal benefit for the heart-rending patient with cancer facing them, knowing that to do so may prevent them from funding 20 or 30 patients requiring eye operations or hip replacements or drugs for schizophrenia, or should they refuse that treatment? Have the Government thought through the implications of devolving the cost-benefit analysis that NICE does so well?
Earl Howe
My Lords, I think the noble Lord has perhaps misunderstood the purpose of the plans that we have set out. Prior to the introduction of value-based pricing, we will continue to ensure that the NHS funds drugs that have been positively appraised by NICE. I hope that that reassures him that clinicians are not going to be placed in an awkward position. We will be consulting on our plans for value-based pricing before the end of the year, but I can assure the House that the point of moving to a new pricing system is to increase patient access to new effective drugs. That is what we aim to do.
Healthcare
Lord Turnberg Excerpts(13 years, 8 months ago)
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Lord Turnberg
My Lords, I have no problem in endorsing the principles described in the White Paper—patients at the centre, devolving responsibility and so on—but they sound rather familiar. There seems to be a close resemblance to the aspirations that came out of the many NHS White Papers and Bills that we have seen in this House over the past few years. I have watched these come and go, as someone who worked for many years as a consultant in the NHS and as a past president of the Royal College of Physicians. The question, as always, is how to implement these fine ideas.
I shall focus on the proposal to change the PCTs to GP consortia. If this sounds familiar, just remember GP fund-holding; the new proposals sound only subtly different. So, if fund-holding and PCTs failed, why should GP consortia work? Success always depended on the enthusiasm and skills of GPs, and unfortunately these are not evenly spread. GP commissioners have to assimilate large amounts of data about their patient populations and their diseases, know about financial and risk management and have statistical skills and an ability to develop contracts—and none of that can be done between seeing patients or after the evening surgery. Little wonder that few have expressed any enthusiasm to take on these responsibilities in the past, nor have they now. GPs will certainly need help. That can come only from re-employing either experienced staff made redundant when the PCTs are disbanded or those from the private sector, who are unlikely to be in the game for charity.
We know that PCTs are not uniformly good at their job; some are excellent while others are less so. The reason is that there just are not enough of the skills needed to go around all 160 of them. If we have a similar, or greater, number of GP commissioners, we will run into the same problems. All this points to a need to keep the numbers small—I reckon no more than 20 or 30. That would allow a small cohort of committed GPs to work with a few experienced managers. The projected cuts in management of 45 per cent just endorse the need to keep the numbers small. What ideas do the Government have about the number of GP commissioners that they envisage?
The numbers are not the only problem, though. The system seems designed to divide primary and secondary care still further. We can talk glibly of “seamless care” between hospital and community, but there are many ways in which these need to be co-ordinated. Indeed, any complicated disease—one has to think only of geriatrics, mental illness, stroke and so on—requires hospital specialists and GPs to work closely together in designing packages of care. It is vital for commissioning bodies to have the direct involvement of specialists in developing contracts for what should be integrated care. What efforts will be made to ensure this vital close collaboration in a competitive climate?
Then there is the question of commissioning for education and training and for research. I have many concerns that, as these are devolved to the local level, they will be lost in the hurly-burly of commissioning for efficient and economical care in the face of savings targets of £20 billion. There is little evidence that GPs will pay more than lip service to the aspiration in the White Paper to “embed research” in the NHS. A recent survey showed that GPs were antipathetic to their being involved in research using patient data, and were unhappy with the extra work involved in obtaining consent from their patients. When key commissioners are so uninterested, it does not bode well for the future of research or teaching in the NHS.
I do not want to say much about the involvement of the private sector in commissioning, save that it is quite unclear what incentives they will have to encourage education, training and research. How will the Government ensure that they will not be damaged in the change to the new arrangements?