NHS: Front-line and Specialised Services

Lord Turnberg Excerpts

Thursday 13th January 2011 Lords Chamber

Asked By

[Lord Turnberg]

To ask Her Majesty’s Government what steps they are taking to ensure that the proposed changes to the National Health Service will not damage front-line and specialised services.

[Lord Turnberg]

My Lords, I suspect that your Lordships may feel that we have had rather a surfeit of debates on the NHS of late, and we have not even seen the Bill yet. However, I am pleased to open this debate as it gives us an opportunity to reflect on what the Minister has said in his previous responses and to try to be constructive in preparing for the Bill.

I should express my interests again as someone who has spent most of his working life in the NHS as a physician and professor of medicine and then as president of the Royal College of Physicians and more recently as scientific adviser to the Association of Medical Research Charities. I am pleased that the noble Baroness, Lady Jolly, will make her maiden speech in this debate. I very much look forward to hearing what she has to say.

In our previous debates a large number of criticisms of the White Paper came up, ranging from the wide extent of the proposed changes and whether they were proportionate to the perceived problems of an NHS of which many noble Lords extol the virtues, to a sense that a damaging commercialisation was creeping in. I have to admit that the previous Government were not immune from reorganisation and re-reorganisation zeal but it is significant that it was only when there was a clear increase in funding and a remarkable rise in the number of nurses and doctors that we saw a real improvement in patient care. So while reorganisations may be necessary at times, it is money that talks. At a time when we will be seeing retrenchment in the service, we must ensure that we do not cut these front-line staff.

I imagine that the Minister is aware of the study carried out by Sir Brian Jarman a few years ago in which he showed that there was a strong negative correlation between the number of doctors in a hospital and the mortality rate in that hospital—the more doctors, the lower the death rate. In that light, are there to be any cuts in the number of trainee doctors in the near future?

I shall mention three specific topics that impinge on front-line services: the pathfinder consortia; integrated services; and research and teaching. The pathfinders should generate a lot of valuable information. Leaving aside the bias that is introduced by the fact that this is a group of self-selecting enthusiasts who may not represent the generality of somewhat disinterested GPs, the data they will produce should be extremely helpful in deciding which paths to go down and which to avoid. After all, that is what I understand by the term “pathfinder”.

So my questions for the noble Earl are, first, will the Department of Health collect information that will help in the design and size of the generality of consortia when they are rolled out? Secondly, what sort of information will be used in this assessment? Will they be those easy to measure data such as waiting lists or waiting times which at best are relevant only to patients needing cold surgery, such as hip operations, but not relevant to the majority of patients you find in hospitals who are usually brought in as emergencies, such as those with heart attacks, strokes or collapses of various sorts? Or will they try to get information on outcomes that are more meaningful for patients, such as how well they were treated as individuals, how quickly they felt better and whether they got back to work, or whether smoking cessation measures have been more successful, how well alcohol reduction programmes are working and whether all these sorts of outcomes are better under the new arrangements? There is a very welcome emphasis on outcomes in the Government’s strategy for cancer, published yesterday. I ask the noble Earl whether a similar approach is intended for the many non-cancer patients faced by the consortia. Many of these outcomes need long-term study, but how else are we going to know whether we are doing any good by these changes? Will the department gather the type of information that can let us know which pathfinders to follow and which to avoid?

I return to the issue of integrated care that everyone—the royal colleges, the BMA, and the King’s Fund—see as the most effective way in which services should be designed and delivered. By integrated care, I mean integration not only across primary care and social services but right across the spectrum, from the community to the secondary care sector where so much of the costs are to be found. You have only to see an elderly patient lingering unnecessarily in an expensive and potentially dangerous hospital bed because of a lack of facilities in the community to recognise the importance of integration of care.

Problems are due not only to lack of facilities, but are equally likely to be due to poor communication between the two parts of what should be a seamless service. It is patients with complex, multiple diseases who form the majority and need seamless, joined-up, care across all three sectors. There are plenty of excellent guidelines to best practice for all these types of patients. The guidelines come from the royal colleges, specialist societies, medical research charities and a variety of other organisations. These guidelines are ripe for adoption by consortia for their contracts. One of the problems in the current NHS has been the slow take-up and implementation of good practice guidance. An obvious example is the national service framework for the care of stroke patients, published a decade ago and not yet fully implemented everywhere. What efforts will be made to encourage the spread of good practice, and how will that be incorporated into contracts by consortia? How will consortia use the expertise and knowledge of clinicians in secondary care and of front-line staff in the community sector? They should be working closely together. How will they overcome the potential barriers to this type of collaboration by the competitive environment and the “any willing provider” concept?

I want to say something about localism and its impact on research. In previous debates, the Minister was reassuringly clear about his commitment to research in the NHS, and the relative protection of the NHS research budget is of course very welcome. I congratulate the noble Earl and Dame Sally Davies on their efforts in achieving this. In this respect, what is to happen to OSCHR, the Office for Strategic Co-ordination of Health Research, the body set up to help co-ordinate research funding between the MRC and the NHS?

My main concern here is the role of GPs and the consortia in commissioning research and teaching. A recent survey by the Association of Medical Research Charities and Involve found that the vast majority of patients were happy to give consent for the use of their personal data for research, but that few GPs were interested in research, and that even the fairly straightforward business of seeking consent from patients was regarded by many as difficult and too time consuming. Therefore, if GPs are to have a key role in NHS research, it will be vital to give them some sort of incentive for their involvement. I should be very interested in hearing more from the noble Earl about how he thinks we might provide this stimulus.

Finally on research, I expect that the Minister will have seen the excellent recent report from the Academy of Medical Sciences, commissioned by his department, on the regulation of research. Is it his expectation that the Government will accept the recommendations in the report, particularly those relevant to streamlining regulation?

I hope I have been a little more constructive today and I look forward to the contributions of other noble Lords and, of course, to the response from the noble Earl.

NHS: Reorganisation

Lord Turnberg Excerpts

Thursday 16th December 2010 Lords Chamber

[Lord Turnberg]

My Lords, I, too, congratulate my noble friend Lord Touhig on introducing the debate at such a cleverly opportune moment.

As a physician who has spent most of his life working, in one guise or another, within the NHS, I have always thought it self-evident that patients have to be right at the centre of the health service and that much greater responsibility for providing that service should be devolved to the professionals in the field. So I cannot fault the Government’s aspirations. However, when we consider how these aims are to be achieved, we run into formidable difficulties and I cannot help but feel apprehensive.

It is with the roles and responsibilities of the GP consortia, which will play a pivotal role in the Government’s plans, that I have most concerns. These concerns are largely shared now by the Royal College of General Practitioners. First, there is a suggestion that there will be 500 consortia. Is that so? If it is, we will have a range of problems. Where will they all get the expertise in managing the contracting for services? We have enough problems with the variability between PCTs in commissioning—some are good and some are poor—and so 500 will be very difficult. Then there is the problem of the extra cost of all the staff and infrastructure needed to run 500 new organisations. I ask the noble Earl: how many do the Government imagine we will need?

On contracting for uncommon or unusual diseases, it is proposed that larger groupings of consortia will be formed to gather together the relevant specialist expertise. So we will then have at least three tiers of commissioning organisations—consortia, super consortia and the commissioning board. This system is ripe for confusion, overlap and a potential for competition between commissioners, to say nothing of the difficulties of hospital trusts faced with a confusing array of contractors. We know from experience with GP fundholding that the kind of arrangement where groups of fundholders are supposed to join forces just does not work.

Of course, it is valuable to devolve responsibility to the local level but we cannot ignore the likely effect of this on the variability of the services provided in, presumably, 500 or so different areas of the country. Is the postcode lottery likely to be made better or worse in such a system? What safeguards will be put in place that will ensure that patients of one consortium do not complain that they are getting lesser treatment than their neighbours? I know that the Minister takes these matters very seriously. I will in a moment make some suggestions that might help him overcome some of the problems.

GPs will now have financial responsibility for the care of their patients. Two tensions will arise. First, GPs will make decisions about what care the patient sitting in front of them in their surgery should or should not have. If they feel that they cannot afford a particular treatment, it is a recipe for a loss of trust by the patient in their doctor. GPs will have that responsibility. Let us remember that they will no longer have the back-up of NICE to take these difficult decisions off their shoulders. The doctor/patient relationship is threatened when doctors are seen to be the agents of rationing on behalf of the NHS. It could, for example, tempt GPs into trying to tailor their list of patients to those with the least demanding diseases.

The second tension will arise from the patient being able to choose from “any willing provider”, as the White Paper puts it. Quite apart from the conflict that could arise between the GP trying to balance the books on the one hand and the patient demanding some expensive treatment on the other, there is the whole question of whether this combination of choice and willing providers conflicts with the efficiency with which the service can run and the equity of access that we all cherish so deeply. I do not think that this issue has been given sufficient attention in the rush to push the changes through.

It is not much wonder that GPs are worried and that the Royal College of General Practitioners has voiced clear concerns. They are worried about the financial risks that will be placed on their shoulders, about their lack of expertise in the new skills that will be expected of them and about the threats to the doctor, patient relationship.

Noble Lords have mentioned integrated care. There seems little doubt that the best way for patients to have access to a safe, effective and efficient service is through those in primary, secondary and social services working closely together both in designing care pathways and delivering the care. In the words of the college of GPs, this is the essential cornerstone of an effective healthcare system.

When I brought this up in our debate on 28 October, the noble Earl expressed his strong support for the concept, but there is unfortunately little information around as to how it might be put into practice. Indeed, the competitive environment gives little encouragement that integrated care will be given more than lip service. So I ask again whether the Minister has any information on how integrated care might be put into practice.

Perhaps I may make three proposals that might help ease some of these difficulties. First, the number of consortia should be kept low—probably no more than 20 to 50. This will keep the costs down, allow specialist expertise in management and contracting to be equally available to them, reduce the number of confusing tiers of commissioning bodies and take a burdensome load off the many reluctant GPs. It will be interesting to hear about the experience of the pathfinder consortia. Clearly they are the keen minority, but I suspect that they would welcome such a proposal.

Secondly, I respectfully suggest that we keep the roles and responsibilities of NICE as they are and do not change them at all, at least until we can see how GPs get on with their new responsibilities. Thirdly and finally, can we see whether it is possible to develop a proper system of commissioning that incorporates the concepts of integrated care?

Department of Health: Arm’s-length Bodies

Lord Turnberg Excerpts

Tuesday 16th November 2010 Lords Chamber

[Earl Howe]

They are different skill sets, but I am not aware that Parliament has visited these issues, let alone revisited them. As I said, we will have the opportunity to do that, but the proposals we have outlined will ensure that the teams that are currently involved in inspection activities will be kept together. I see no reason why they should not be.

[Lord Turnberg]

My Lords, perhaps I may ask the noble Earl about the Health Protection Agency. What advantages does he expect to come out of moving the HPA into the Department of Health?

Mental Health

Lord Turnberg Excerpts

Wednesday 10th November 2010 Lords Chamber

[Earl Howe]

My Lords, my noble friend is absolutely right: this is a cross-government effort. It is not simply for the Department of Health to deal with the issue because just about every department has some sort of remit in this area. I would say that, in particular on the attainment of children at school, we will focus very much on children from disadvantaged backgrounds because there is a high correlation between mental ill health and poverty, and mental ill health and deprivation. That will be a major focus.

[Lord Turnberg]

My Lords, what steps are the Government taking to ensure that GP consortia have access to the expert advice they will need if they are to commission positive mental health messages and the prevention of mental illness?

[Earl Howe]

My Lords, many GPs understand the issues very well and are keen to get on with the agenda. Our proposed model of GP commissioning means that practices will have flexibility within the new legislative framework to form consortia in ways designed to secure the best healthcare and outcomes for their patients. That will include mental health and could involve, for example, taking commissioning decisions collectively with perhaps a lead consortium for mental health.

Health: Chronic Fatigue Syndrome

Lord Turnberg Excerpts

Monday 8th November 2010 Lords Chamber

[Earl Howe]

My Lords, I am afraid I cannot give that figure as it is not in my brief, but I will write to my noble friend.

[Lord Turnberg]

My Lords, is it not the case that we have not been able to discover the cause of this very unpleasant disease so far and we have no real effective treatments? While we are waiting for both of those, the best form of management seems to be cognitive behavioural therapy. Does he agree?

[Earl Howe]

My Lords, cognitive behavioural therapy is indeed part of the NICE recommendations, but only a part in so far as it is appropriate for any chronic condition to have such therapy. I am sure that the noble Lord agrees that the NICE guidance recognised a clinical and physical basis to this condition as well. Therefore, a multifactorial approach is appropriate.

Health: NICE

Lord Turnberg Excerpts

Wednesday 3rd November 2010 Lords Chamber

[Earl Howe]

My noble friend is, as ever, on the case. My officials in the Department of Health are in active discussions with their counterparts in each of the devolved Administrations on the kinds of changes that we envisage to the pricing of medicines.

[Lord Turnberg]

Does the Minister agree that to devolve responsibility for prescribing expensive drugs to GPs faces them with a very difficult ethical dilemma? Should they prescribe a very expensive drug, costing thousands of pounds, with only marginal benefit for the heart-rending patient with cancer facing them, knowing that to do so may prevent them from funding 20 or 30 patients requiring eye operations or hip replacements or drugs for schizophrenia, or should they refuse that treatment? Have the Government thought through the implications of devolving the cost-benefit analysis that NICE does so well?

[Earl Howe]

My Lords, I think the noble Lord has perhaps misunderstood the purpose of the plans that we have set out. Prior to the introduction of value-based pricing, we will continue to ensure that the NHS funds drugs that have been positively appraised by NICE. I hope that that reassures him that clinicians are not going to be placed in an awkward position. We will be consulting on our plans for value-based pricing before the end of the year, but I can assure the House that the point of moving to a new pricing system is to increase patient access to new effective drugs. That is what we aim to do.

Healthcare

Lord Turnberg Excerpts

Thursday 28th October 2010 Lords Chamber

[Lord Turnberg]

My Lords, I have no problem in endorsing the principles described in the White Paper—patients at the centre, devolving responsibility and so on—but they sound rather familiar. There seems to be a close resemblance to the aspirations that came out of the many NHS White Papers and Bills that we have seen in this House over the past few years. I have watched these come and go, as someone who worked for many years as a consultant in the NHS and as a past president of the Royal College of Physicians. The question, as always, is how to implement these fine ideas.

I shall focus on the proposal to change the PCTs to GP consortia. If this sounds familiar, just remember GP fund-holding; the new proposals sound only subtly different. So, if fund-holding and PCTs failed, why should GP consortia work? Success always depended on the enthusiasm and skills of GPs, and unfortunately these are not evenly spread. GP commissioners have to assimilate large amounts of data about their patient populations and their diseases, know about financial and risk management and have statistical skills and an ability to develop contracts—and none of that can be done between seeing patients or after the evening surgery. Little wonder that few have expressed any enthusiasm to take on these responsibilities in the past, nor have they now. GPs will certainly need help. That can come only from re-employing either experienced staff made redundant when the PCTs are disbanded or those from the private sector, who are unlikely to be in the game for charity.

We know that PCTs are not uniformly good at their job; some are excellent while others are less so. The reason is that there just are not enough of the skills needed to go around all 160 of them. If we have a similar, or greater, number of GP commissioners, we will run into the same problems. All this points to a need to keep the numbers small—I reckon no more than 20 or 30. That would allow a small cohort of committed GPs to work with a few experienced managers. The projected cuts in management of 45 per cent just endorse the need to keep the numbers small. What ideas do the Government have about the number of GP commissioners that they envisage?

The numbers are not the only problem, though. The system seems designed to divide primary and secondary care still further. We can talk glibly of “seamless care” between hospital and community, but there are many ways in which these need to be co-ordinated. Indeed, any complicated disease—one has to think only of geriatrics, mental illness, stroke and so on—requires hospital specialists and GPs to work closely together in designing packages of care. It is vital for commissioning bodies to have the direct involvement of specialists in developing contracts for what should be integrated care. What efforts will be made to ensure this vital close collaboration in a competitive climate?

Then there is the question of commissioning for education and training and for research. I have many concerns that, as these are devolved to the local level, they will be lost in the hurly-burly of commissioning for efficient and economical care in the face of savings targets of £20 billion. There is little evidence that GPs will pay more than lip service to the aspiration in the White Paper to “embed research” in the NHS. A recent survey showed that GPs were antipathetic to their being involved in research using patient data, and were unhappy with the extra work involved in obtaining consent from their patients. When key commissioners are so uninterested, it does not bode well for the future of research or teaching in the NHS.

I do not want to say much about the involvement of the private sector in commissioning, save that it is quite unclear what incentives they will have to encourage education, training and research. How will the Government ensure that they will not be damaged in the change to the new arrangements?