Health and Social Care Bill
Lord Turnberg Excerpts(13 years, 7 months ago)
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Baroness Williams of Crosby
My Lords, I have Amendment 112 and 113 in this group. I have a comment regarding the excellent speech of the noble Baroness, Lady Cumberlege, and would like the Minister to reply to it. NICE has suggested that all women expecting babies could have the right to consider the possibility of a caesarean birth. Before the choice is finally made, will that be associated with advice from doctors indicating that caesarean births are certainly not as straightforward as some people believe them to be, and for cosmetic reasons may be deeply regretted afterwards? I was a little worried that NICE had given this green light, as it were, to caesarean births without associating it with any form of counselling to the mothers concerned, not least because, as many people in this House will know, the outcomes in terms of morbidity and infant mortality are not as good as people imagine them to be in comparison with a normal birth. Perhaps the Minister could say something about that. Perhaps the noble Baroness, Lady Cumberlege, could also say something about it when she responds on her useful and important amendments, to which I hope the House will give an extremely warm welcome.
Amendments 112 and 113 are about strengthening the language about health inequalities. On that issue, we have had a helpful letter from the noble Earl, Lord Howe, dated 24 November, in which he sets out in detail some of the steps that will be taken, not least the creation of the Institute of Health Equity, to deal with health inequalities. My question is rather a big one but it boils down to the old problem of how one ensures that these worthy and excellent intentions are actually carried out.
The House will remember that new Section 13F of the 2006 Act proposed in Clause 20, which deals with the autonomy of clinical commissioning groups from the Commissioning Board and restricts the board’s actions in terms of having to bear that autonomy in mind, was put into a different set of considerations—the consideration of the whole of the responsibility of the Secretary of State and the responsibilities of the boards—under the headings of Clauses 4 and 10.
All of this means that we are still debating these issues without being clear about where responsibility for them ultimately lies. I do not propose to go over that ground again, but it is appropriate for this debate to notice that the whole set of duties that are laid out in detail—and to which this debate will undoubtedly add as it lays down further duties for clinical commissioning groups and the board as a whole—in a sense therefore depends upon the outcome of those discussions about the constitutional structure. That matters because we need to bear it in mind all the way through our consideration of the duties that are laid upon clinical commissioning groups.
What makes me, to be honest, even more concerned is that I recently read the discussion paper The NHS: Developing Commissioning Support, which was quite improperly, no doubt, leaked on the internet. My attention was drawn to it by a couple of doctors who had access to the internet. The paper sets out in detail the ultimate objective of moving towards a commercial market in the health service and sets it out under a considerable number of different headings. For example, there is a specific mention in this report that,
“Clinical commissioning groups will have a statutory freedom to secure the commissioning support from wherever they want”.
It goes on to say that the commissioning support should be given in a vibrant, commercial market. What worries me about all this is that I am not at all clear—and never have been in our long debate on health—about what the ultimate goal is. I suspect that we are discussing two things at the same time. One is the attempt to keep improving the existing NHS, sometimes by an extraordinary degree of micromanagement—from this House, I have to say. The other is the determination of many people in this House to ensure the safety and continuation of the NHS which is free at the point of need and which is available to people regardless of their ability to pay. Somewhere along the line and at some point, we really have to be clear what we are talking about. I do not know whether others taking part in this debate share my sense that we are walking in without knowing the constitutional responsibilities and quite where we are going.
I commend my two amendments. They both strengthen the words on equality of health outcomes. I congratulate the Government very much on establishing the Institute of Health Equity and carrying forward the detailed research we are now doing on lifestyles and many other things, which are important and which I am sure the whole House will applaud. However, I have to raise the big question about destinations. I hope that at some point before we abandon the Committee stage, we will have a clearer view about the Government’s ultimate destination: whether it is to retain an NHS; whether it is to make it more open to innovation and other contributions from the private sector, with which many of us would certainly not disagree; or whether the ultimate outcome is to move towards a commercial market system, this being essentially a transitional stage.
Lord Turnberg
My Lords, this is a disparate group of amendments. I support a number of them. Some seem to be counter to others, but I hope that they will come together at some point. Amendment 110A seeks to strengthen the need to take into account the guidance from NICE. From time to time, NICE faces someone complaining about the way it goes about its business. Sometimes patient groups suggest that it is taking its time or is working against their best interests. The pharmaceutical industry complains from time to time that it takes too long and maybe gets things wrong—perhaps that is a good thing on behalf of NICE. Others complain about the methodology that NICE uses, using QALYs—quality-adjusted life years—as its measure of whether a drug or treatment is effective. Despite all that, I believe that NICE does a marvellous job, as do many who know what it does. It makes sure that the suggestion of treatments is based on clear, independent evidence of their effectiveness. Its approval is something of a kitemark for the standards that GPs and PCTs should follow and the system is envied across the world. There are others trying to emulate NICE.
Lord Turnberg
I wish to speak to some of the amendments that are in my name. I would also like to comment briefly on Amendments 128A and 129, dealing with innovation. We know that we are quite slow in taking up innovations in the UK. It is not simply that there is a bit of sluggishness in the system—there are hurdles in the system. I want to mention two examples of very simple innovations that would not cost any money to the health service, but which have been blocked by the systems under which we operate.
One example is a consultant colleague of mine, a gastroenterologist—my own field—who set up a clinic in which he took phone calls from GPs and patients and was able to answer many questions without actually having to see the patients. It had a rapid turnover. It was considered to be innovative but was blocked because it did not earn any money for the hospital trust which found that it was not getting the patients referred. The second example concerns a similar situation in which the same consultant saw new patients from 8 am until 9.30 am. He sent them away for tests, scans, endoscopies and so on, and saw them again at about 11 am with the results of the tests and gave them the treatment that was necessary. This, too, was considered not to be earning money for the PCT, because it was paid for items of service, and it would have got twice the money with the normal system. This is a hurdle to innovation which we should surely be able to overcome. We have discussed that with the Minister. He expressed sympathy for the idea so I hope that it can be acted upon. It is not simply that we are slow; we have hurdles.
I come to Amendments 130, 131 and a number of others in my name. I have no doubt that the Government have firm intentions to promote research and innovation. It is mentioned in several places in the Bill and I know that the noble Earl’s heart is in the right place on all this. The amendments in my name are simply there to help the Government in their own aspirations by emphasising and reiterating the need to keep research and innovation at the forefront. I simply emphasise the points made so eloquently by the noble Baroness, Lady Morgan, and the noble Lord, Lord Willis. The amendments make it clear that innovation and research are of such central importance that they should be explicit in the board’s business plans, in reporting its activities and in clarifying how it is going about achieving these aspirations. The amendments make sure that the board actively promotes research as against simply having regard to it. I hope that the Minister will find the amendments helpful in the light of the Government’s intentions.
Amendment 131 returns to the issue of research that protects the public’s health. Here I make two particular points that the Minister might consider answering in one way or another. First, how will it be possible to ensure that the local authorities taking over the directors of public health also promote research? What levers will there be with the local authorities? Secondly, I ask a question that has been posed before. How will we ensure that the Health Protection Agency, which engages in much important research, will have access to external funds? We have discussed this before, but it would be nice to know whether it is clear that the HPA will have access to grants from external funding bodies.
Earl Howe
My Lords, the NHS has a long and proud track record of innovating and delivering better care for patients. That must continue—we all agree about that. That is why new Section 13K of the 2006 Act places a duty on the board to promote innovation when exercising its functions, including innovation in the provision of services and the,
“arrangements made for their provision”.
That last phrase means the commissioning of services. As a result, although we completely sympathise with the principle behind Amendment 128A, it is not necessary. The duty is intended to support the delivery of quality and productivity improvements across the NHS to help transform healthcare for patients and the public. In response to the noble Lord, Lord Warner, I say that I expect that innovation in procurement of goods and services will be an essential part of this. The duty certainly allows for it as it stands. It is an important part of the QIPP programme at the moment, and I am sure that it will continue to be. If we were to specify one area of activity in which the duty should be exercised, as Amendment 129 suggests, we would face the perennial problem of listing those areas where the duty should be exercised to the detriment—
Health and Social Care Bill
Lord Turnberg Excerpts(13 years, 7 months ago)
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Lord Ribeiro
My Lords, I thank the noble Baroness, Lady Thornton, for her comments about integration, because I agree with her that we do not have a clear definition. On page 18 of the Bill, new Section 13M is headed:
“Duty as to promoting integration”.
Although the words “integration” and “integrated” are used in the section, there is no clear definition. Yet, in new subsection 4, there is an attempt to define “health-related services” and “social care services”, but not until new Section 13Z3 is there an interpretation which tries to define the “health service” and “health services”. We do need some clear definition of what we mean by integration. Let me tell you what I thought integration meant, when I first took on an interest in the Bill, and I will illustrate it with some examples.
Integration, for me, was not being able to talk to my GP colleague about a patient without having to go through the PCT. I could not just pick up the telephone and say, “I’ll see your patient next Friday”. It had to go through a bureaucratic system before the patient got to me.
From a clinical point of view, when I was referred a patient with gallstones on a Monday morning clinic, after discussing and examining the patient, confirming that she did indeed have gallstones—and I used to have an ultrasound machine in my out-patient clinic, so it was easy to make the diagnosis—I said to her, “I think we can deal with this quite easily with a keyhole operation to remove your gallbladder, but I suspect you may also have an ulcer in your stomach, so before I put you on the list for surgery, it might be a good idea to exclude that”. I went down the corridor to see my gastroenterology colleague, told him about the problem, and he said, “Not an issue, bring her along, and I’ll see her”. Before I knew it, I had had a phone call saying, “I will deal with her next Thursday and gastroscope her”.
The net result of that was that within a week we had an answer for the lady, and I was able to put her on the waiting list for surgery. However, when choice and tariffs came in, it was essential, for the hospital to be paid, that when the patient came to see me in the outpatients’ clinic and was diagnosed with gallstones, I would have to refer her back to her GP, who would then make another consultation with the clinician gastroenterologist in order for her to have the endoscopy to diagnose her ulcer. Those were two inconvenient visits for that patient, purely to fulfil the need to manage the tariff and the issues around choice.
For me, an integrated service gets rid of all those barriers. We should also remember that this is the Health and Social Care Bill; it is about integrating services from the beginning to the end. I have tremendous sympathy and support for Amendments 103 and 290, from the noble Lord, Lord Warner, because they are about getting rid of episodic care. It was precisely the episodic tariffs that required my patient to make two visits to the hospital when one would have done. I hope the Minister will take this into consideration when reviewing this. It is important that we find a formula, or a way to look at the care pathway, and find a way to cost that, rather than the episodic costing of care.
Lord Turnberg
My Lords, I will speak to Amendments 103, 104A, 106, 135A, and several of the others in this group. Clause 20, new Section 13M, highlights integration of services as something the Commissioning Board should “exercise its functions” to secure,
“where it considers that this would—
(a) improve the quality of those services”.
That is all well and good, but by itself it seems insufficient. Integration is of course difficult to pin down. We have heard quite a bit about that this evening, and I will not repeat those remarks. I know what I mean by integration, so I will give you my particular understanding, for the purposes I want to talk about, using the term to mean a seamless service for those patients, usually elderly and with multiple diseases, who need both hospital and community care, and flit between the two.
It is unfortunately the case that the integration that is needed between health and social services has seen so many failures and been so elusive, despite many wasted words. We have an opportunity here to correct these failures, so I was somewhat disappointed when the Minister said in the debate on 2 November, when we were discussing the role of the Secretary of State, that the Government were,
“not in the business of dictating the processes”—
and that—
“integration is neither a necessary nor a sufficient condition of a good outcome”.—[Official Report, 2/11/11; col. 1334.]
Surely if integrated care is a good thing—and I think few will deny that—then we must give a lead on how it might be achieved. We cannot ignore the process, and must at least try to see what conditions are necessary for successful integration. We should not go around simply saying it is a good thing, without showing how it might be achieved.
There are many examples out there that we can build upon. We are not entirely in uncharted territory. The noble Baroness, Lady Cumberlege, mentioned Assura Cambridge and services in Torbay in our last debate, and other noble Lords spoke of Kaiser Permanente, Northern Ireland, personal health budgets and information sharing, as valuable means to an end.
We also have the excellent report from the Nuffield Trust, Integration in Action, that analyses successful integration being carried out in four places across the world, including in Scotland. We are not working in a vacuum, and we could and should take advantage of all this information, and incorporate some of those ideas in the Bill without waiting for yet further work.
Of course, not everything can or should be put in the Bill, but we should see where we can strengthen it, by including more pointers to how we can improve the present, very unsatisfactory, position. Let me give some examples, leaning heavily on the Nuffield Trust report. First, the Commissioning Board should point the way by developing commissioning for bundled payments, and local tariffs for key conditions. I think that is possible. At the moment, fees for service for episodes of hospital care, as we have heard, work against integration with community service. That is something that the board should seek to redress quickly.
Secondly, we should design the national tariffs that we have heard about, which incorporate a full care pathway across the health and social service divide. Monitor and the board should work together to develop a pricing strategy that provides the incentives for integration. They should also develop ideas about how outcome measures, which are admittedly difficult to quantify when we are talking about a complex system like integrated care between hospital and social care, can be used to promote integration across the whole pathway of care. Contracts based on those measures can encourage providers to respond to the need to integrate. There is nothing here that obviates competition between providers, which I am sure will please my noble friend Lord Warner.
We will come later in the Bill to Monitor, but it too should link improvements in outcomes, including the patient’s experience, to the way it regulates integration. Then, there are several measures that clinical commissioning groups and local authorities should be encouraged to develop by the Commissioning Board. One huge area is of the improvements we desperately need in the flow of information between hospitals and community. Too often we rely on phone calls on the day of discharge, which is inefficient and fails most of the time. We should have an IT system which allows information to be shared across the divide. It only requires a competent programmer to produce the programme, and a safe system for preserving patient confidentiality and data protection. I am sure that that is not beyond our capacity.
There is also the need for joint funding and integrated governance arrangements, which we have had some discussion about. This is much easier said than done, but it can be done. We have seen it in action here and there and we must spread the good practice.
There is also the need for people to make the whole thing work on the ground: for example, liaison officers whose sole responsibility is to ensure that patients pass seamlessly across the divide, and nurses and doctors who move without constraint from one sphere to another. The example of specialist district nurses is a good one. They follow patients from hospital to the community and back, and are very much appreciated. Unfortunately, they are a threatened species and are disappearing, largely because neither the NHS nor local authorities will fund them. We must get around that problem.
Of course, much of what is needed depends on a change in the mindset of those working at the coalface in hospitals and the community. If through the Bill we can change the conditions from those that inhibit collaboration to those that encourage it, we can begin the process. The amendments bring a greater sense of the need to focus more strongly and urgently on the duties and responsibilities of the board in putting integration more firmly on the map as a way of improving outcomes. I support them strongly.
Baroness Hollins
My Lords, I will speak to Amendment 203A in my name and those of my noble friend Lady Finlay and the noble Lords, Lord Patel of Bradford and Lord Patel. I will speak also in support of Amendments 135C and 135D, tabled by my noble friend Lady Finlay.
The Bill seems to favour the commissioning of services through the any-qualified-provider model rather than being concerned primarily with commissioning an integrated model of care. Amendment 203A would introduce a duty on clinical commissioning groups to commission multiple providers of health services competing to deliver a section of the care pathway only where they can demonstrate to the NHS Commissioning Board that the approach is beneficial to patients. Integrated care pathways are particularly important in complex, long-term conditions such as serious mental illness or challenging behaviour, for example in someone with learning disabilities who is also on the autistic spectrum.
There have been attempts in the NHS to deliver integrated care pathways, with varying degrees of success. The introduction of a plurality of providers in mental health services in recent years is already showing signs of fragmenting complex care pathways in some instances. The disaster of Winterbourne View is just one example of how commissioning one provider to deliver part of a pathway without planning, commissioning and co-ordinating the whole of an integrated pathway can be an expensive and tragic mistake.
The further introduction of competition between providers has the aim of reducing the cost of provision while maintaining and improving the standard. This is a noble aim on which we may all be able to agree. However, commissioners must evaluate whether the aim is being achieved, recognising that care pathways vary hugely in different conditions and even for different patients. The variety of provision needed means that we cannot easily—if at all—prescribe a rule to cover all situations. Of course, the health service exists to serve patients, not providers. It is in this light that we must consider proposals to introduce competition between providers, and it is because of this that the burden of proof must be on those who favour increasing competition to show that doing so would benefit patients.
The risk is that many providers will compete to provide more profitable parts of a pathway, cherry-picking the parts they would like to offer, perhaps only to the least complex patients, thus leaving unmet the less easy to cost and define but still essential parts of the pathway. The importance of an integrated care pathway cannot be overestimated. The comfort patients take in knowing that their entire provision is being dealt with in a coherent, joined-up way may be put at risk under an any-qualified-provider system. As always, it is the most vulnerable patients whose needs may remain unmet.
Health Research Authority (Establishment and Constitution) Order 2011
Lord Turnberg Excerpts(13 years, 7 months ago)
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Lord Turnberg
That the Grand Committee do consider the Health Research Authority (Establishment and Constitution) Order 2011 (SI 2011/2323).
Lord Turnberg
My Lords, this instrument is to set up the Health Research Authority as a special health authority. The main reason given for taking this step rather than the primary legislation route is because there is some urgency in finding a home for the national research ethics committees that will soon find themselves homeless when the strategic health authorities and the National Patient Safety Agency go out of business.
I can, of course, understand why it is necessary to go down this rapid secondary legislation route because even if the Health Research Authority were to find a place in the current Health and Social Care Bill, it would still be a couple of years before it would be fully enacted and we need something sooner. However, there remains the question of why it cannot be put into the Bill as well so that there can be a smooth transition from this temporary solution to a more permanent one. No doubt, we will be exploring that when we come to debate it later in the Bill.
The anxiety remains that we will have to wait a considerable amount of time before we see another round of primary legislation to set up a permanent agency. In our debates on the Bill yesterday, we heard about the doubts being expressed about when we will see further legislation. Can the Minister enlarge on the hint he gave in the debate last week that we might see something relevant to this in 2012?
It might be helpful if I said a few words about why the establishment of a health research authority or agency is so important. It comes directly from the recommendations in the Academy of Medical Sciences’s report A New Pathway for the Regulation and Governance of Health Research which the Government commissioned last year and which, to their credit, they have endorsed enthusiastically. The report described in great detail the current regulatory burden faced by clinical researchers and proposed a number of solutions, the most important of which was setting up this agency. It pointed out how the UK research effort is being undermined by an overly complex regulatory and governance environment and how this has caused a fall in the UK’s global share of patients in clinical trials of all types, as well as a marked increase in the time needed to navigate a very complex research approval process. Regulation has grown as new regulatory bodies have been set up, often in response to some scandal or other, and often with seemingly good reason, but without any consideration of the overall impact of yet another new hurdle and without any evidence whatever that they have improved the safety of patients or the public.
The problem is confounded by the delays and duplication in the governance arrangements within individual NHS trusts. They are now thought to be the single greatest barrier to health research, especially where several trusts are involved in multicentre trials, for example. There is a definite need for a regulatory pathway that allows us to cut through all this unnecessary and complex bureaucracy while at the same time ensuring the safety and interests of patients.
Now we have a research regulatory authority as an important government response, and we have to see how it is going to achieve all that is expected of it. First, the National Research Ethics Service, with its 80 or so local ethics committees, has done a marvellous job in the past few years in streamlining the ethics approval process. It has, for example, made it much easier for those engaged in multicentre research proposals to gain approval. Preserving its function has been vital, but unfortunately moving it by itself from one body to another will do no more than preserve the status quo. It simply moves it from one home to another, yet the research regulatory agency was expected to do so much more.
My questions for the noble Earl are: will the authority have any more responsibilities? For example, will it have any of the responsibilities currently undertaken by the ethics and confidentiality committee of the National Information Governance Board? That committee advises the Secretary of State on whether permission should be given to researchers wanting to use data about patients where it is not possible to gain consent. It is a very important safeguard for patients, but it means that researchers have to have two sets of ethical permission to do the research, one from a normal ethics committee and another from this committee, and that causes all sorts of delays. Can we expect some streamlining here? I see in the Explanatory Memorandum to this order that that might be on the horizon. If so, can the Minister give any further information on that and on when it might happen?
Then there is the problem posed by the delays caused by the local R&D committees in each of the NHS trusts. They can hold up research for months, especially if more than one trust is involved in multicentre research proposals. For example, Cancer Research UK said that the average time for a multicentre research grant to be approved was over 600 days. Can the noble Earl say whether the new authority will have any role in easing that problem, perhaps by ensuring that limits are set on the times that trusts can take in considering proposals? Will it, for example, be able to vet research proposals in such a way that it can save local R&D committees from each having to repeat much of the straightforward common areas of a proposal, leaving them to check on aspects of specific local importance? That would certainly help to speed up the process.
The excellent report from the academy outlines a whole range of other regulatory bodies and functions that could and should be rolled up into the new authority. I shall not go into them, save to recommend that noble Lords who have not read the report might find it of some interest.
A research regulatory authority or agency has enormous potential for good if we can get it right. If we do, all will benefit—the researchers, certainly, but most importantly the patients, who will access new treatments sooner and more efficiently. We will gain economically too, because we will regain something that we are already losing: the investment from the pharmaceutical industry, which is watching our debates with interest.
We owe a debt of gratitude to the Government for setting up this authority and removing the uncertainty surrounding the ethics committee, but much more needs doing. I look forward with interest to the response of the noble Earl, Lord Howe.
Lord Willis of Knaresborough
My Lords, first, I apologise to the noble Lord, Lord Turnberg, for arriving one minute into his speech; I did not realise that the earlier business would have been dispatched so summarily this afternoon. I am grateful to him for introducing the debate and giving us an opportunity to address the issues he raised ahead of discussions during the passage of the Health and Social Care Bill, to which there are clear amendments on some of these issues. Like him, I say to the Minister without hesitation that I welcome the establishment of this special health authority. He promised it in answer to questions some time after I had arrived in the House and saw the need to move on the academy’s report as quickly as possible, and I compliment him and the Government for moving so speedily; there is no issue about that.
The need to find a home for the National Research Ethics Service was important. There was haemorrhaging of staff and good will and, in terms of any research project, it is important that you have a stable, effective and well respected ethics service. We probably have the best research ethics service in the world. We welcome the appointment of Janet Wisely, the current chairman of NRES, as the new chief officer for the Health Research Authority; she is well respected and that level of continuity will serve us well.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I thank the noble Lord, Lord Turnberg, for his positive comments on the creation of the HRA as a special health authority and welcome the opportunity of this debate to clarify the role of the authority on its establishment on 1 December. As I said last week when we discussed amendments to the Health and Social Care Bill, the Government have signalled their clear and strong support for research by increasing the research budget of the Department of Health in real terms over the current spending review period. I fully recognise the importance of ensuring that research is promoted within the health service. High quality health research is critical to the ability of the NHS to deliver world-class health outcomes, an end towards which we are all striving.
I think that noble Lords will agree that regulation of research is excessively complex. Both this and inconsistent local practices need to be addressed. As the Academy of Medical Sciences’s report set out, it is still far too difficult for researchers to navigate the complex national and local processes for research approvals. The Plan for Growth, which was published alongside the Budget 2011, announced the Government’s proposals. At the national level, we said that we would create a Health Research Authority to combine and streamline the approvals for health research, which are scattered across many organisations. At a local level, we said that we would transform the incentives for efficiency in research initiation and delivery. These two components are critical and we are already tackling the complex local processes for research approvals. Through the Health and Social Care Bill and the efforts of my department and the National Institute for Health Research, we are seeking to embed a positive and proactive research culture across the depth and breadth of the NHS. The noble Lord, Lord Turnberg, asked me what we are going to do about delays at trust level, and that question was echoed by the noble Baroness, Lady Finlay.
We have developed a co-ordinated system for gaining NHS permission for research that is supported by the National Institute for Health Research. It aims to standardise the checks that lead to trust approval, and centralise those that do not have to be carried out locally. In May we fulfilled our commitment to launch a framework of good practice and standard procedures to facilitate consistent local research management and greatly improve performance.
NHS trusts which adopt these standards will stop unnecessary duplication of checks, a local barrier to getting a research project off the ground that has frustrated researchers for many years. For clinical trials the National Institute for Health Research will publish outcomes against public benchmarks, including—and I address this particularly to my noble friend Lord Willis—an initial 70-day benchmark to recruit the first patient to a trial. Future NIHR funding will be conditional on meeting benchmarks.
I turn back to national-level commitments. The instruments not only fulfil our commitment to establish the Health Research Authority as a special health authority this year; alongside the directions we are giving it, they also ensure that the Health Research Authority will have substantive functions from the outset.
First, the HRA will unify the existing functions of the National Research Ethics Service from the National Patient Safety Agency and strategic health authorities. This will provide continuity and a stable platform for the National Research Ethics Service to build on the achievements it has already made. For example, a major obstacle to conducting research has been the completion of the numerous forms required to gain research approvals and permissions. The Health Research Authority will continue to run the integrated research application system developed by the National Research Ethics Service. It is an online one-stop shop that lets researchers apply for all the research approvals they need, not just to ethics committees but to NHS trusts and other health research approval bodies.
Secondly, in addition to ethical approvals, and from the outset, the HRA will have duties to co-operate with other bodies to improve the whole system: to create a unified research approval process and to promote consistent standards for compliance and inspection. This means it will promote alignment across the whole system, working closely with other bodies, such as other regulators. For example, it will work with the Medicines and Healthcare Products Regulatory Agency on operating a co-ordinated national approval process for research involving medicines or medical devices. It will also work with the National Institute for Health Research on promoting proportionate action to demonstrate compliance with standards that are consistent on both the regulatory and provider sides. Therefore, it will support the work of the National Institute for Health Research to promote improvements in local NHS approval processes.
Thirdly, and most importantly, from the outset the HRA’s role will be to protect and promote the interests of patients and the public. It is crucial that members of the public participating in research are—and feel—safe. The HRA will protect patients from unethical research, and enable patients to benefit from opportunities to participate in research by facilitating research which conforms to ethical standards and the law. Its role in combining and streamlining health research approvals, alongside the work of the National Institute for Health Research with NHS trusts, will improve the timeliness of decisions about research projects. This will increase opportunities for our patients to benefit from research.
The noble Lord, Lord Turnberg, asked about the ethics and confidentiality committee function within the National Information Governance Board for Health and Social Care. The NIGB is an independent statutory body established to improve and monitor information and governance in health and adult social care. It provides advice to the Secretary of State on the appropriate use, sharing and protection of patient and service user information. In particular, it has set up a committee—the ethics and confidentiality committee—for advice on the processing of patient information, including confidential patient information, under the Health Service (Control of Patient Information) Regulations 2002. Confidential patient information may be processed under those regulations only where the processing has been approved by the Secretary of State and, in the case of medical research, also by a research ethics committee. It is intended that the HRA will take on the Secretary of State’s role in approving the processing of such information for medical research as part of its role in combining and streamlining approvals for health research. The establishment of the HRA will help to ensure that the application and review processes are streamlined and, as I have said, follow consistent standards.
My noble friend Lord Willis asked me to summarise the functions of the HRA as a special health authority. I have already mentioned that it will assume the NRES functions from the NPSA as well as strategic health authorities’ functions as the appointing authorities for research ethics committees. In due course, it will perform the Secretary of State’s function of approving the processing of patient information for medical research. My noble friend mentioned the reference to directions in the order. Principally, those directions will relate to the need for the HRA to co-operate in the exercise of its functions with the regulatory bodies that I have referred to and with others.
My noble friend asked whether the Government have any intention to transfer HFEA or HDA functions into the special health authority. The answer is no, because we cannot. As a special health authority, the Health Research Authority is generally restricted to exercising the Secretary of State’s functions relating to the health service in England. Establishing it as an NDPB in due course will enable functions to be conferred on it which are not specific to the health service in England, including giving it functions which go beyond health, including functions relating to social care. The Academy of Medical Sciences’s report proposed that the research-related functions of the HFEA should reside with the Health Research Authority. We will be consulting on the future of the HFEA and on our preferred option that the research-related functions of the HFEA should pass to the HRA. Establishing the HRA as an NDPB will enable it in due course to take on functions relating to embryo research which are not health service functions in England.
The noble Baroness, Lady Finlay, asked me about indemnity for research and the possibility of an all-England risk pool. Trusts are members of the NHS clinical negligence scheme, which indemnifies them in respect of negligence for which they have assumed vicarious liability, whether the negligent activity was standard care or research.
The noble Baroness, Lady Thornton, asked about other functions of the NPSA and, in particular, the National Reporting and Learning Service and the National Clinical Assessment Service. I will write to her on that, but I can tell her that most of the NPSA’s functions are expected to transfer to the NHS Commissioning Board after Royal Assent. Patient safety will of course be at the heart of the new system. Responsibility for national confidential patient inquiries has already moved to the Healthcare Quality Improvement Partnership, which manages the national clinical audit programme.
The noble Baroness also asked me about the cost of the Health Research Authority. The funding will follow the functions. The Health Research Authority will continue the reform of the National Research Ethics Service releasing efficiency savings, we trust, for developing the authority’s other functions.
Looking forward, it is important to ensure that we maintain momentum and build on the advances that the Health Research Authority will be able to take forward as a special health authority. It is our intention to publish draft clauses on the Health Research Authority for pre-legislative scrutiny in the second Session. Future legislation will allow us to establish the Health Research Authority as a stable and independent non-departmental public body. The current regulatory framework for health research involves many overlapping acts and instruments, so there is much work to be done to ensure that we develop legislation that is fit for purpose.
Research has been a core function of the National Health Service since its foundation. It is key to the future of health and healthcare in the UK. The creation of the Health Research Authority as a special health authority is, I believe, an important step on the road to removing unnecessary bureaucracy that could stifle research in this country.
I am most grateful for the support of noble Lords. We will no doubt be returning to these issues when debating amendments tabled to the Health and Social Care Bill. In the mean time, I recognise the value of these exchanges and thank all who have contributed so fully to this debate.
Lord Turnberg
My Lords, the noble Earl said that in future the NIHR will require trusts to have a 70-day limit on the time in which it can consider requests. Does that also reflect on non-NIHR-funded research from other organisations or is it only NIHR research?
Earl Howe
My Lords, the precise arrangements for the CSND are being worked through at the moment. I will write to the noble Baroness on that. As I have described, the incentive relates directly to the NIHR funding but the benchmark is measured against other research and all studies that are going on. There is a wider dimension to this.
Lord Turnberg
I should apologise to the noble Earl for burdening his day off from the health Bill during several weeks of hard work. I thank him for his detailed response and will reflect carefully on what he has said. Today’s debate will be useful when we debate this issue in the health Bill proper on the Floor of the House. I hope that it will reduce the amount of time that we discuss the Bill, although I cannot promise that. We will wait and see.
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Baroness Pitkeathley
My Lords, charities have been campaigning about the VAT issue for many years. My charitable interests are declared in the Register of Members’ Interests. Without doubt, the VAT issue is an unfair burden and a major inequality in the charitable sector. Why should it be of concern to us? Let us think of what charities are good at. In addition to the services outlined by noble Lords already, charities are good at spotting gaps and funding innovative solutions. They are good at bridging gaps, especially between health and social care. They are very good at seeing patients or service users in their particular situations and providing services which meet their needs and not some notional need determined by an assessor. Those things are going to be tremendously important in the new NHS going forward.
Noble Lords should think of the contributions to care and health made by helplines, information provision, carer support groups and specialist nurses. They should think of the particularly significant service of incontinence supplies and advice—so vital to people with disabilities and to older people and their carers—provided extensively by charities. It is vital that charities are not only encouraged to continue to participate, but are also supported to do so—and not to be made subject to additional burdens such as those that noble Lords have outlined. The NHS and social care service cannot do without these services and, most importantly, patients, users and carers cannot do without them. Therefore, we must make it as easy as possible to provide for all qualified providers, including charities. I support the amendment.
Lord Turnberg
My Lords, I rise to lend my support for this amendment. I speak here as a trustee of the Wolfson Foundation, which has a programme of support for hospices and care homes and over the years has given many millions of pounds, largely for capital projects. VAT is a constant source of unhappiness to the trustees, and, in fact, they have reached the conclusion that they will no longer pay VAT for capital projects. This means, of course, that the hospices and care homes themselves will have to find that money, which is unfortunate. Therefore, I hope that the Minister will take this amendment seriously.
Lord Warner
My Lords, I support the amendment and I do so from a background of having been the chairman of the National Council for Voluntary Organisations and a trustee of a number of organisations that have supplied services to the NHS and local government. This is indeed a very long-running sore; it is a source of grievance. It often goes with another grievance—one which is not germane to this debate but which I might as well mention, because it explains why voluntary organisations are sometimes reluctant to provide some services for public authorities. That is a kind of meanness, almost, on the part of many public bodies about meeting the administrative costs—the management costs—of local authorities. If one takes the two together—a meanness about meeting management costs and being treated unfairly on VAT—this is a barrier to entry.
I fully support the points made by the noble Baroness, Lady Finlay. As the Minister knows, I have probably made myself a little unpopular on these Benches through my support for the idea of competition on a level playing field. I have a later amendment which raises the issue of barriers to entry. This is a barrier to entry. It is stopping voluntary organisations participating fully on the basis of a level playing field as a qualified provider. Therefore, in terms of the Government’s own philosophy in the area of competition, they would do well to listen to these arguments and remove this barrier to entry.
Lord Turnberg
My Lords, my name is attached to Amendment 47B, so ably introduced by my noble friend Lord Warner. I simply wish to emphasise some of the points that he has raised and some of those raised by the noble Lord, Lord Kakkar. The amendment is an attempt to fill a conspicuous gap in the Bill in relation to education and training—namely, to introduce at this stage the idea that we have a Health Education England. I recognise of course that we are waiting for further information from the Future Forum and that we should expect further legislation on this in due course, but this is a subject on which we cannot afford to wait. We need something in this Bill, if only to try to settle some of the many uncertainties that are so disabling for many out there. We cannot wait for a second Bill at some uncertain and probably distant time.
The White Paper Liberating the NHS: Developing the Healthcare Workforce is frankly disturbing in some of its recommendations. Putting responsibility for education and training at the local level entirely in the hands of provider networks—so-called local skills networks—is to my mind, and that of many I have spoken to, both dangerous and potentially damaging. Of course we need, and should have, local input in planning for local workforce needs. However, the standards of education and the level of skills and knowledge that patients deserve have to be set on a national scale. It is not helpful to have a healthcare worker trained solely for local needs who is unable to transfer to another part of the country without going through another local training scheme. Training must be transferable. For that we need national curricula, assessments and levels of achievement, so that when a new healthcare worker joins an organisation, the organisation can rely on that training.
At the moment, for medicine at least, the GMC sets the overall standard and the royal colleges and their specialist advisory committees provide all the curricula and set the exams, assessments and qualifications so that employers and patients can rely on the fact that a newly appointed cardiologist or surgeon, for example, has reached a recognised and approved standard on a national scale. However, most of the medical, nursing and other training takes place at the coal face: in the wards or in general practice by trainers who are themselves practitioners. Here, out and about, the postgraduate deans play the pivotal role because they oversee the whole process of training and planning of the workforce for their part of the country. The deans are the glue that makes it all happen. They control, of course, the budgets for the salaries of all the medical trainees. At the moment, they are employed by the strategic health authorities. When those authorities disappear, the current proposal is for them to be taken over by local provider skills networks. I have already suggested that it would be unfortunate if these bodies were purely NHS providers with little input from those with experience of what education and training entails. Providers may know something about what they want out of it at the end, but they are not set up to oversee and provide the education by themselves.
There are two things that must happen if we are to have a reliable system. First, Health Education England must be set up now, as this amendment suggests. This organisation should become a focus for the postgraduate deans and should probably be their employer. Secondly, we must make more use of the expertise in education that lies in the universities across the country. While universities are engaged in nurse education and that of some other healthcare workers, we must be one of the few countries in the world where universities play little or no formal role in postgraduate medical education. Of course, most clinical professors and their staff are engaged in teaching postgraduates, but the universities have no formal roles. It makes quite a bit of sense, therefore, to consider having the universities play a much bigger role in the local skills networks with the NHS providers. The postgraduate deans might indeed be employed by the universities if they are not to go into Health Education England, although I am not suggesting that their budgets go across to the universities—that may be a step too far.
Perhaps I may ask the Minister whether it would be possible for the deans to be seconded to the local university. It might well be a valuable outcome if the deans could then work closely with local NHS/academic partnerships rather than with NHS providers alone. The example of the academic/health service partnerships set up as collaborations between the NHS and universities to encourage research and the transfer of innovation into practice, as initiated at UCL, might be worth following, and I hope that it might find favour with the Minister. A new partnership built on this kind of model, with deans, providers and universities, and advice from the royal colleges and oversight from Health Education England, would, I believe, find a lot of favour. It would not be providers alone, and it would not be universities alone—where we have seen some of the difficulties associated with nurse education—but a balanced combination of the two. I hope that we can see something emerge along those lines. If that is seen to be the general direction of travel now, even if the detail comes later when we have seen the Future Forum’s report, it will settle many of the anxieties that exist.
I understand that there is an intention to set up an interim Health Education England some time next year, but unless it is given the budget for education, some £5 billion a year, and if the money is instead diffused into local skills networks in the meanwhile, I fear that it will be lost for ever. That is why we should have a clear statement in the Bill now about Health Education England and its funding.
The other part of the amendment refers to the need to ensure that the funding for education and training is not eroded in the changeover, and I hope that the Minister can give us some comfort there, too.
I know that there is much more work to be done by the Government, but we should not leave this until some uncertain future. We must have something a little more concrete in this Bill, and I hope that the Minister will be able to help us.
Baroness Emerton
My Lords, I have put my name to Amendment 47B. At Second Reading, I referred to why I thought it important that education and training be mentioned in the Bill, even though it was understood that work was already under way. Noble Lords who have spoken have underlined the importance of education and training being mentioned in statute now.
The Health and Social Care Bill proposes a comprehensive health service reliant on an effective workforce that is capable and competent to deliver a service that demonstrates improved patient outcomes. For this to happen, there needs to be an effective partnership between the NHS and universities. The introduction of local commissioning of services will also require local commissioning for education and training places for the agreed workforce plan at both local and national level. There must be multi-professional involvement if professional silos are to be avoided, both in relation to funding and the structures and governance arrangements that underpin the workforce. For too long, silos have been the problem in the funding arrangements for education, training and research.
Developments around the establishment of Health Education England are now being considered, but, as has already been said, progress is slow and is causing anxiety out in the field. The intent to move to an integrated health and social care service calls for these partnership arrangements to be made. There is a need to ensure the right balance of responsibility and accountability between Health Education England and the provider-led networks—employers/professions, the education sector and the whole workforce, plus patient and public representatives, working together. It is vital that this is a proper partnership and representation on the boards of local education and training boards, which can ensure effective multi-professional workforce planning. Representation of universities, medical schools and postgraduate deaneries, in relation to both non-medical and medical education, on the board of the local education training boards will ensure effective co-production of the healthcare workforce.
Universities should not be considered simply providers of education programmes but also co-producers of the workforce through this wider role of research, innovation, releasing social capital, and the globalisation of healthcare, which is integral to the development of advanced clinical care, service redesign and workforce planning. Universities should work in co-operation with the NHS to ensure the delivery of high-quality education and training and then be held to account by Health Education England. Ensuring that universities are a central part of the local education will facilitate effective partnerships, improved quality outcomes and a multi-professional approach.
The intent to move to this is very important and the establishment of budgets, which has already been mentioned, is also crucial. As already stated, silos should be avoided so that an integrated approach can be established to the education and training of the workforce. The challenge for the new education system will be whether it can truly ensure the co-product of a workforce that can deliver the new way that care can be delivered—one that will provide holistic care, especially adapting to the demographic changes, demanding more care in the community for the elderly, frail, vulnerable and for end-of-life care. Budgets will need to reflect the most cost-effective provision of care to enable hospital expenditure to be reduced.
Nursing, midwifery and other allied healthcare professions are committed to evidence-based practice and would warmly welcome the multi-professional involvement in education and training programmes as well as the benefit gained from multi-professional buildings and shared facilities. Not only would this be of benefit for the learning environments but it could be cost-effective in the use of expensive educational facilities, tutorial staffing and equipment. Could the Minister clarify some of these issues in his summing up?
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Lord Turnberg
My Lords, I rise to speak to Amendments 40A and 199ZA in my name. I also want to comment on some other amendments in this group. I speak as a one-time medical researcher, a trustee of a number of medical research charities, and as a scientific adviser to the Association of Medical Research Charities. In that I work closely with my friend, the noble Lord, Lord Willis.
Research, as we have heard, is not an optional extra. It cannot be added on to the NHS as and when someone thinks it is needed; it is a vital and integral part and it is good to see an acknowledgement of that in the Bill, even if it falls a little short of full endorsement. Research is no cottage industry, with more than £1 billion coming from the research charities every year and almost the same amount going in from each of the Medical Research Council and the NIHR. That is a total of around £3 billion a year. As for the Department of Health’s contribution of almost £1 billion, I want to say how much Dame Sally Davies's role in securing that is appreciated, as indeed is that of the noble Earl who has been a great ally. However, Amendment 42 raises the question of whether this funding is secure for the future.
I can only re-emphasise what the noble Lords, Lord Willis and Lord Warner, have said. Even though research funding amounts to less than 1 per cent of the NHS budget—a pitifully small proportion in an organisation of this size—can we be reassured that it will not fall easy victim to the cuts we are going to see over the next few years? Is it really essential for this to be distributed through the Commissioning Board? Is it possible that it could come more directly via the Department of Health? I hope that the noble Earl will give us some comfort on this amendment. This is clearly of some importance and we almost certainly will have to come back to it at a later stage.
As we have heard, medical research in the United Kingdom punches way above its weight. By any measure, our outputs of research findings come high in any international league table and the fruits of our research are having a major impact on our health. We are living longer and healthier lives and one has only to look around your Lordships’ House to see evidence of that. I suspect that there are few of us who are not taking one or more pills, keeping us in fine fettle. As the noble Lord, Lord Willis, said, the public at large is well aware of the benefits. According to a number of surveys, more than 90 per cent of patients and the public want us to do this research and, furthermore, want to be engaged in it as patients. They want this even if it does not benefit them directly but benefits only future generations. However, they also know that any patient who is part of a trial incidentally gets a better deal and better care as part of the research process.
They are enthusiastic supporters but that is not the only reason why we should be supporting research. There are considerable economic benefits too. The most recent of several studies that have shown this, Medical Research: What's it Worth? supported by the Rand Foundation and the Wellcome Trust, clearly showed that we gain between 35 and 40 per cent return per annum for every pound we put in. Although it takes several years for research done now to bear fruit—today it is coming from research done some years ago—the returns come from less sickness and absenteeism from work, greater productivity and less sickness benefit payments.
Research is a good thing all round and this Bill is a great opportunity to make sure we gain its full benefits. Amendment 39 emphasises the need for the Secretary of State to take his expressed desire to support research seriously and I strongly support that amendment. Amendment 199ZA, in my name, brings the same pressure on to the clinical commissioning groups and alters the wording in exactly the same way. It is at this level where I fear we have seen one of the biggest obstacles to promoting clinical research up to now. The same survey I mentioned earlier showing that patients are keen to be involved in research also showed that GPs by and large were antipathetic to and at best uninterested in research. Few GPs engage in research directly themselves, but that is not the main problem. It is their unhappiness at having to spare any time, for example, in seeking the approval of their patients for them even to be approached by researchers and asked for their consent.
Researchers have to ask patients for consent but can do so only if the GP asks the patients for them first, and they are not at all keen. They say that there is not enough time. Yet their role is critical, not only to facilitate clinical research performed by others but to be responsible, through the CCGs, for commissioning those extra support costs that arise when research, funded by charities, the MRC and so on, is carried out. Research on patients supported, for example, by the British Heart Foundation or Cancer Research UK, often results in additional costs due to extra visits or more routine blood tests. Traditionally these should be funded by the commissioners of services. This Bill provides just the opportunity we need to make sure that those at the coal face, responsible for commissioning, can facilitate and fund this research.
I hope the Minister will consider the need to accept this or a similar amendment and examine how we might provide the inducements necessary to GPs and CCGs. A failure of CCGs to take on responsibility for creating the right environment in which we can gain the full value of external funders will be damaging.
I come now to the difficult issue of the use of patient data. How can we make sure it is possible to use clinical information about patients for research purposes? New Section 14X, to be inserted by Clause 23, describes the duties of clinical commissioning groups to promote research and includes the need to promote the use of evidence obtained from research for improving the health service. That is very good, but it says nothing of the other way round; of how we can use patients’ data for research purposes. The amendment in my name, Amendment 199ZA, emphasises this point. The difficulty has been well rehearsed: how does one gain access to identifiable information about patients for research into their diseases while at the same time protecting their confidentiality and giving them all the reassurances that they need? It so happens that well over 90 per cent of patients are happy for information about them to be used for research, but the current system of safeguards goes well beyond the requirements of the Data Protection Act and is stifling much important research.
When data about patients are fully anonymised—a horrible word—and it is impossible for anyone including the researchers to identify a patient, then there is little or no trouble. However, when it is necessary for the researchers to know who the patients are, we get into problems. If, for instance, a researcher needed to use the cancer registry to look at whether patients with a given cancer were subject to some factors in their environment—for example, whether they lived near electricity pylons or some hazardous waste plant—then they would need to seek consent from each patient. But what if many have died in the mean time or are untraceable because they have moved away or gone abroad? It becomes impossible to do the research. The National Information Governance Board was set up for this purpose, but it is no more. I know that the Government intend to try to help with this now. I know that as a first step the patient information leaflet produced by the UK Clinical Research Collaboration, explaining how data about them can be used, has gone out to GP practices in Scotland and soon will be sent out in England and the rest of the UK. That is an excellent start. The Clinical Practice Research Data Link has also been set up, but I wonder whether the Minister can say how far we have got with that? Will it achieve what is needed: the rapid access to data for researchers with the approval of patients? Meanwhile this amendment seeks to flush out the need to address this hurdle to some important research.
Amendment 41 brings up the important issue of funding for public health research. Here I speak as a former chairman of the Public Health Laboratory Service, the forerunner of the Health Protection Agency, which is also disappearing. I cannot speak too highly of the marvellous work it did and does in protecting the public’s health. It is a fantastic organisation. It works on outbreaks of food poisoning, epidemics of flu and immunisation programmes against a whole host of infections, to say nothing of its work in radiological protection and on all sorts of biohazards. The point is that this organisation is at the forefront of its field and is the envy of the world because it is able to do fantastic world-leading research. It is highly dependent on a continuing research effort to keep ahead of the infections and other hazards that are continually evolving. It is vital that it continues to have access to research grant funds, particularly external grant income from the whole range of potential funders to which it has access now, such as the Medical Research Council, the Wellcome Trust and so on. I hope the noble Earl will reassure us on this. His Written Answer to the noble Lord, Lord Willis, yesterday did not give any confidence that the Public Health Laboratory Service will be able to apply to external bodies for funding.
Then there are the directors of public health and their teams. They, too, should be enabled to conduct high-quality research. The amendment makes that clear. How will they receive the necessary support and encouragement when they transfer into the local authorities? It is not at all clear that local authorities are keyed into this, so some reassurance on this point would be helpful. Most of these amendments are probing—I think they all are—and seek simply to gain a greater understanding of the ways in which I hope the Government will support the research effort.
Lord Ribeiro
My Lords, I shall speak in support of Amendments 40 and 42, which, as the noble Lord, Lord Willis, said, are very much appreciated and welcomed. They reflect the Government’s acceptance of the importance of research and making this an express duty on the Secretary of State.
Some years ago, Professor Sackett made the medical profession aware of the term “evidence-based medicine”. I should like to think that we have all adopted it in our clinical practices over the years. As a surgeon, I speak from a surgical perspective. In the 18th century John Hunter was approached by Edward Jenner with his dilemma about children in Gloucestershire who were being afflicted by cowpox. He wrote to John Hunter, saying, “I’m thinking about doing something about this and would like to cure the children in this area with a vaccination made from cowpox”. John Hunter replied, “Don’t think about it, do the experiment”. We in surgery consider Hunter the father of scientific surgery but our problem is that we are, perhaps, not quite as cerebral as our physician colleagues. All they have to do is learn the discipline, acquire the knowledge and prescribe the tablets. On the other hand, we not only have to learn but must then apply our knowledge in carrying out the operation. There are two skills that we must acquire. For us poor surgeons, it is often a long sentence—spent not only in a laboratory but in the theatre, putting into practice what we have learnt.
Earlier, a noble Lord—I think it was the noble Lord, Lord Warner—used the term “from the bedside to the bench”, which is very important. The whole concept behind translational research has been to get our trainees and doctors away from idea that all they have to do is stay in the lab, beavering away. It is about the patient. One of the things that surgeons try to do is take a problem from the bedside into the lab, apply stringent tests to it and then bring it back in the form of treatment, which might be by medication or an operative technique.
Earl Howe
I am most grateful to the noble Lord. In that case I shall not dwell on it at great length.
Amendment 40A, tabled by the noble Lord, Lord Turnberg, and other noble Lords, would require the Secretary of State to have regard to the need to promote the use of information derived from patients for research purposes while taking full account of the confidentiality of information. I welcome the intent behind this amendment, but it is in fact unnecessary. We recognise the important role that patient data, if treated carefully and confidentially—and that I hope goes without saying—can play in improving the quality of health research. I spoke earlier about our consultation document An Information Revolution, in which we propose that the most important source of data is the patient’s or the service user’s care record generated at the point of care. Information in these records also provides much of the data needed for other secondary purposes: for commissioners, for managers, for care professionals and, importantly, for research. We are using the responses that we received to the consultation, together with the findings of the NHS Future Forum, to develop an information strategy for health and social care in England. This will highlight how increased transparency and greater access to information supports improvements in care and research. It is the major work stream. I can reassure the noble Lord that we value the use of patient information where confidentiality is appropriately protected as a source of research and that we are looking at ways to embed its use in our information strategy.
Lord Turnberg
Can the noble Earl give us any idea of the timescale over which we might see something emerging from this? It has been on the agenda for a very long time and we really need to move on it.
Earl Howe
I hope that I am not putting my neck on the block, but within a month the noble Lord should hear news that may cheer him on this front.
A great many noble Lords have asked me questions, some of which I have covered, but I suggest that in the interests of time it might be helpful if I followed up this debate in writing and in a way that will enable me to answer the questions in greater detail than I would now in any event.
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Baroness Thornton
Eight noble Lords have amendments down in this group about inequalities. Many of them seek to do the same kinds of thing. I intend to speak to Amendments 22, 25A, 27A—I mention in passing that my noble friend Lord Beecham has his name against Amendment 29—31, 32, 68A, 68B, 69B and 120A.
I will quickly run through these amendments. Amendments 21, 22, 23 and 25 strengthen the duty on the Secretary of State to reduce inequalities in the health service. The Bill currently requires the Secretary of State simply to “have regard to” this need. Amendment 21 says “is required”—the strongest of these amendments—followed by Amendment 22 with “seek”, and Amendment 23 with “act with a view”. Amendment 25A says it is the Secretary of State’s duty to reduce inequalities between people and “between communities” in England. I will return to that in a moment. In Amendment 27A, we on this side are seeking to add detail to the inequalities that the Secretary of State has a duty to reduce. We argue that,
“inequalities in health status, outcomes and experience, … the outcomes achieved … by … those services”,
and,
“ability to access such services”,
must be taken into consideration. My noble friend Lord Beecham has added his name to the amendment in the name of the noble Lord, Lord Rooker. It adds a qualifier to the duty to reduce inequalities:
“to ensure that greater patient choice is not accorded a higher priority than tackling health inequalities”.
Amendment 31 says that, in an instance of a conflict of duties on commissioners or regulators, the duty to reduce inequalities is paramount. Amendment 32 says that, as part of this duty, the Secretary of State must publish comprehensive, publicly available data on the extent to which inequalities have been reduced across the NHS. Amendment 68A says that the duties of the NHS Commissioning Board as to the improvement of public health should be extended to cover the duty to reduce health inequalities. Amendment 68B concerns each local authority having to take steps to reduce health inequalities between people and between communities. Amendment 69B again relates to public health: the Secretary of State must also seek to reduce health inequalities between people and communities. Finally, Amendments 120A, 190A and 190B are about the national health Commissioning Board having a duty to reduce inequalities in health status. Noble Lords will get the theme that is running through here.
Clause 3 places a duty on the Secretary of State to have regard to health inequalities, and that is an aim and aspiration that we would, of course, support. However, the problem with this clause is that that duty is not capable of effective fulfilment. For example, public health analysis and needs assessment require comprehensive area-based population data. This is the basis of the current health system mechanisms for resource allocation and for the commissioning of public health measures designed to prevent or ameliorate systematic inequalities both between groups of residents in an area and across and among areas, with respect to the access of resources, services, and their use and outcomes. Census estimates, adjusted for factors such as age and deprivation, are used as the denominator for the population in such analyses. Our problem with this Bill is—and I would be grateful if the Minister would address this issue—that public health analysis will not be able to be carried out in this way in future because of the proposed shift from area-based PCTs to GP-listed clinical commissioning group structures. Therefore, denominators which allow GP registrations to promote reductions in inequalities might be inherently problematic because of continuous enrolment and disenrolment, which affect accuracy, as does patient selection. The denominator will not be representative of all the people in a geographically bounded area. Without a geographic population focus, it will not be possible to monitor inequalities. I realise that part of these issues is also addressed in amendments needed to Clauses 7 and 10, but they are points which we would like to have addressed here.
Amendments 120A and 190A address the argument that local authorities and clinical commissioning groups should have a duty to reduce inequalities not only in their areas, but also in England. We think this makes sense because, for example, somewhere like Lambeth or Bradford—where I come from—could make huge improvements within area inequalities but still lag miles behind the rest of the country. Amendment 25A calls on the Secretary of State to act to reduce inequalities between people and communities. The word “communities” is important in this context because it speaks to local authorities. Given that public health inequalities are going to be in their jurisdiction, it seems that this is an important matter. Therefore, we would like the Bill to address within-area geographical inequality because it refers to inequalities between groups and communities of groups, not just an individual’s access and receipt of services. We believe that the Government should set out how they intend to use non-legislative levers and incentives to translate the duties in the Bill into practical action and how the NHS will be accountable for progress in reducing health inequalities. Our Amendments 31 and 32 tie in with this. We think we need to understand where those levers will exist, how they will be used and how the Government will measure inequalities.
As noble Lords will realise, Amendments 120B and 190B also arise directly out of the Equality Act and concern individuals and discrimination in the receipt of services. I know the noble Baroness, Lady Greengross, will address Amendment 33, which is tabled in her name. We believe that Amendment 120B addresses the general duties of the national Commissioning Board, which are vital parts of the picture. If the duties to deliver and secure provision of the health service are split between the Secretary of State, the board and CCGs, corresponding duties to reduce inequalities must also be exercised by all three, and these amendments seek to put that in the Bill.
Lord Turnberg
My Lords, I had not intended to speak to these amendments, but it is clear that we have had problems associated with inequalities for a very long time, and they persist. Many years ago, we had the Black report on inequalities in health, which was a major landmark, and since then we have had Sir Michael Marmot and his marvellous book The Status Syndrome pushing away at the inequalities in health, and my noble friend Lord Layard and his book on happiness and the inequalities in life in general. There is no doubt that the effects of inequalities are very severe. We see quite marked differences in health and life expectancies in communities adjacent to those where life expectancy is very high. We have some communities where several years of life are lost. The effects are very severe indeed. The reasons why there are such inequalities are multiple. They are certainly way beyond the ambit of a health Bill. Clearly there are factors outside health services that make the difference. Nevertheless, it is important that we have within a health Bill recognition of that fact and of the need for those within a health service to take account of inequalities and make recommendations as a result of them, so I am very much in favour of these amendments. We should have them in the Bill.
Baroness Williams of Crosby
My Lords, I am grateful to the noble Baroness, Lady Thornton, for so clearly analysing the different amendments. I shall keep to those that are grouped together. As she said, the gravamen of the amendments is towards the view that the duties of the Secretary of State and, indeed, of other bodies involved in the NHS should be strengthened and put in rather more forceful terms. Whether one prefers “require” or “with a view to”, those words strengthen the position with regard to health inequalities from the rather low-level pressure of “with regard to”.
I say right away that my noble friend Lord Howe said, and I thought said very strongly, that this Bill contains a great many references to inequalities. It is also absolutely true that, as the noble Lord, Lord Turnberg, said, doing something about them is a very difficult exercise. One of the striking findings of the wonderful book The Spirit Level, which I have referred to before in this House, is that where there are grave inequalities in society, there are almost invariably grave inequalities in health as well. As the noble Lord, Lord Turnberg, said, the two are very closely related. Blame cannot be put entirely, or even largely, on the health service for the continuing inequalities. We know that there are very grave inequalities, both geographical and generational, between different parts of our society. To take only one example, lifestyles that feed bad health tend to be rather different between one section of society and another. I shall quote the words of the King’s Fund on the attempt made by the previous Government, to whom I give due credit, to deal with inequalities using the quality and outcomes framework. There was not much effect. The King’s Fund dismissed the whole effort with slightly contemptuous phraseology. It referred to,
“a medicalised and mechanistic approach to managing chronic disease”,
which is fairly damning. In addition, we know that economic differences between regions are very often reflected in health outcomes and, therefore, that looking at health outcomes has to be related to other outcomes: educational, income and social.
Health and Social Care Bill
Lord Turnberg Excerpts(13 years, 8 months ago)
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Lord Turnberg
My Lords, I rise to support these amendments. I agree with virtually everything that my noble friend Lord Warner has said. However, I disagreed with the assertion that Clause 2 may not be the right place for the measure. Clause 2 is headed “The Secretary of State’s duty as to improvement in quality of services”. If there is anywhere that needs improvement, it is in the integration of services. Therefore, I think this clause is the ideal place to insert the measure.
There is general agreement that the principle of seamless care—that is another term for integration, from the point of view I am talking about—for individual patients is a good one and we should support it. By that I mean the ease with which patients can move between one set of carers, hospitals, homes and social care and another. At the moment it does not seem to happen as well as it should in many places, so the Bill is, theoretically, a way in which we can stimulate the mechanism by which it can all happen. However, for integration of care between providers to happen with the minimum of disruption to the individual patient, we need to ensure that there is much more collaboration and consultation between them. It is not only between doctors, nurses and other carers that this collaboration is needed, but particularly across the divides between those funding and managing the different care streams. That is where these amendments can help.
At the moment, we have patients waiting for far too long, as we have heard, in an environment unsuited to their needs—elderly patients sitting in acute hospital beds waiting far too long to go home or into social care. A range of problems get in the way, such as a lack of planning, a lack of facilities, or closure at the weekend of offices where these arrangements should be made. To me, integrated care means the close working arrangements that allow not only the rapid and efficient transfer of patients but the ability to discuss the best course of treatment for a given patient. It means the ready consultation between different specialists, perhaps in different hospitals. It means different trusts, whereby patients can have access to the best treatment available.
I am reminded of the example of orthopaedic surgeons, some of whom specialised closely in hand surgery or re-do hip surgery—second operations on hips that have gone wrong the first time round. Those highly specialised orthopaedic surgeons are not available in every hospital. The ability of one group of orthopaedic surgeons to transfer a patient to the best care possible in another hospital should not be thwarted. We should not be putting any barriers to ready consultations and, if necessary, the transfer between hospitals of patients seeking the forms of treatment that are most relevant to them.
Of course, competition is seen as a driver to improving standards. However, let us be clear; there must be a balance between competition and integration, and between competition and collaboration. I am pleased that Monitor will, I believe, have a role in improving integrated care. I hope that we can persuade the commissioners and providers to support integration also. That is why I support these amendments.
The Archbishop of York
My Lords, I also support the amendment. Like the previous noble Lords who have spoken, I think that this amendment should be put into this part of the Bill. As the noble Lord has just said, the Secretary of State’s duty is to improve the quality of services. The greatest need in our nation is to ensure that the quality of services is improved. How is that to be done? The amendment is a helpful pointer to integrating the clinical delivery of health and social care. The Secretary of State should have a duty to make sure that the delivery of those is integrated. I also know that if that is not done, the duty—already provided for in the first two subsections—will not be carried out. Integrating the delivery of services will be important.
I already have my copy showing how the new NHS structure will work, and if the noble Earl wants a copy, he is more than welcome to have one. The proposed structure of the reformed NHS under the Bill is complex. Some of the relationships are not clearly defined. I happen to believe that integrating the delivery of health and social care will go some way to addressing this complex structure. People will know that the two areas are being integrated in their delivery. The NHS Commissioning Board is of course key, and will become even more so in the case of the failure of a clinical commissioning group. I should have thought that the Commissioning Board needs to know that it is working to make sure that both services are integrated.
It is also clear in the Bill that the role of Monitor will need to be defined and watched carefully if it is not going be the route for introducing harmful levels of competition. If you are going to integrate the delivery of health and social care, Monitor and whoever is delivering will have to be sure that this is being done in an integrated way. Part of the solution, it seems to me, is to ensure the clinical integration of the delivery of health and social care. The amendment is intended to ensure that there is another, further duty on the Secretary of State to ensure the delivery is integrated.
NHS Commissioning Board Authority (Establishment and Constitution) Order 2011
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Baroness Barker
My Lords, reading these regulations, I was taken back to 2008, when the then Government set up the Care Quality Commission. We had a set of regulations that were not dissimilar to these to start the process of establishing that board. The CQC became operational on 1 April 2009; its chair was appointed on 15 April 2008 and spent a year in the process of setting up that body. Noble Lords who took part in the legislation around that discussion will remember that we had not begun the Committee stage when the chair was appointed, and there were in subsequent weeks major discussions about the role of the CQC board, its objectives and its composition, all of which were subsequently translated into legislation and regulations and which today carry through into the CQC.
Echoing some but not all the questions asked by the noble Baroness, Lady Thornton, and the noble Lord, Lord Warner, I too want to ask the Minister whether, as with the setting up of previous bodies, it is the intent that there should be an initial process when a basic structure for establishing the body takes place, and whether it will be added to and changed as the legislation governing the body goes through Parliament. I too want to know whether this board will be required to meet in public, if that is the outcome of the debates that your Lordships are due to have in the next few weeks on the legislation. Also, is it a de minimis position to have five members? That might well be changed in future. Like the noble Lord, Lord Warner, I want to understand the scale of the budget and staffing structure that this board has to oversee.
Can the Minister say more about conflicts of interest? In these regulations, we have a clear but standard definition of conflict of interest, which is about pecuniary interests of board members. This board is going to operate in relation not just to the Secretary of State but to clinical commissioning groups, which opens up the capacity for there to be different conflicts of interest other than direct pecuniary ones, which I imagine that the Government can foresee and would wish to prevent. Would it be reasonable for noble Lords to assume that as the legislation progresses matters like that will be decided and will be the subject of further regulation?
Finally, how long does the department believe the process of transition will take and who will be responsible for monitoring the cost of the establishment of what I take to be a shadow board, which, as I said, is not an unprecedented step for a Government to take in a matter such as this?
Lord Turnberg
My Lords, many of the points that I might have raised have been raised by my noble friends, but I still have some concerns and quite a lot of confusion as to what this body will do. Will it have budgetary responsibilities from day one and, if not, when will it start having some responsibilities for the huge amount of money at its disposal? What controls will be placed upon it? If it is going to meet in public only occasionally, who will hold it to account if things seem to be going wrong? What role will the Secretary of State play if it does not seem to be delivering what it should? It has an enormous set of responsibilities. Will it have sub-committees or will it be decided, among the five non-execs and others, how it will go about its business? I find the whole thing rather confusing at this stage. It would be nice to have some clarity and I hope that the noble Earl will be able to give it.
Lord Willis of Knaresborough
Perhaps I might say first to my noble friend that I support and appreciate the idea of bringing forward a special health authority to shadow the new Commissioning Board. That is right and proper but, like other noble Lords, I think the idea of doing that is a little confusing before we have had a chance to examine this proposal in Committee, and to test it against the large number of amendments which are coming in to tease out what role the Commissioning Board will ultimately perform and what its form and functions will be.
I do not want to add to the questions asked by my noble friend Lady Barker, the noble Baroness, Lady Thornton, and the noble Lord, Lord Warner, all of which I am sure the Minister will get to in his response, but I particularly want to raise one issue with my noble friend. It is the question of research; he will not be surprised that I have raised that. In another place, the Government conceded that research ought to be put into the Bill and that it will be a duty not only of the Secretary of State but of the Commissioning Board and commissioning groups to promote research. At the moment, research within the NHS is of course promoted by the Chief Medical Officer of health, who has responsibilities for the National Institute for Medical Research. To be fair, I think that Sally Davies carries that job out very well indeed. She has done a remarkable job since the Cooksey report and the setting-up of OSCHR with the identifying of resources within the NHS for research. We are starting to see the fruits of that work; indeed, during the passage of the health Bill I hope to be able to speed up the process of getting a special health authority for research and, ultimately, a new research authority.
However, will this shadow authority have a duty to commission research? In which case, will that budget be within the £80 billion to £100 billion identified by noble Lords? Will it in fact take over the duties currently held by the Chief Medical Officer, Sally Davies, or will she continue to retain them and report to the Commissioning Board? In short, where will NHS research reside and who will have authority for it in making the decisions within the new arrangements?
Health and Social Care Bill
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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
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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.