National Health Service
Lord Turnberg Excerpts(8 years, 5 months ago)
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Lord Turnberg
That this House takes note of the ability of the National Health Service to meet present and future demands.
Lord Turnberg (Lab)
My Lords, I am extremely grateful for the opportunity to open this debate and delighted that so many noble Lords have agreed to speak. I very much look forward to the maiden speech of the noble Baroness, Lady Watkins of Tavistock. I am only sorry that speakers have only three minutes to express their views.
It seems entirely possible that one or two noble Lords might draw attention to the parlous state of funding of the NHS. They may even echo Matthew Parris when he wrote:
“Our health service is heading, if not for the rocks, then for the sandbank of chronically sub-optimal performance and monthly threats of insolvency”.
It is tempting to say that this cannot go on. But of course it always does, because of the people in it—the nurses, the doctors, the physios, the porters and so on—who work their socks off to do their very best, despite the lack of resources. They regard it as a privilege to work in a service that aims to care for people and their ills, as indeed did I during most of my working life. When the NHS works well, there is nothing quite like it and the public know that. But when staff morale is at a low ebb, as it certainly now is, and when we have a Secretary of State who seems quick to lay blame but is quite incapable of showing the least sign of appreciation of the staff, then that impacts directly on patient care.
I would not want to be ungrateful for the bit of light relief provided by the Chancellor in the recent spending review, even though that was partly achieved by robbing the budgets for public health, education and NICE. It is hard not to feel, as do the Health Foundation and the Nuffield Council, that this is just another emergency bailout—a temporary fix—when the basic underfunding continues apace as the NHS tries to cope with an ever increasing demand. Having said all that, I hope that I do not disappoint the Minister if I say that I will not be taking that line, at least not yet. What I want to do is to lay out what would be an ideal system for providing total care for the population in the community and in hospital. None of what I say will be entirely foreign or original. Perhaps you know what they say about originality: it is the art of concealing your sources. My sources will be obvious.
The ideal service would have to be completely joined up, with social services, general practice and hospital care integrated. That is so often talked about but rarely achieved because it requires the integration of management and, often, the budget. The silos of primary and secondary care would disappear as GPs were able to work as a team across the divide, in and out of hospital, perhaps even under the same management. This may be a pipe dream, and many—perhaps most—GPs would object, but enough may see the advantages, especially now when they are under such unsustainable pressure that so many are thinking of giving up. Health visitors and district nurses, as well as social workers, could be employed by the hospital so that they could be completely integrated. They would be able to see their patients in hospital as easily as in general practice and the community, without this delaying referral system we have set up.
We had a debate before Christmas about the problems of the care home sector. A number of significant private providers are threatening to go out of business with the potential loss of a large number of care home beds. Currently, about one-third of acute hospital beds are already occupied by patients who would be better cared for in the community. Even more pressure may be put on those beds as care homes are lost.
Would it not be much better if hospital trusts opened their own care homes? A bed in their care homes would cost them about half what a hospital bed costs them, and the trusts would save money and beds—a no-brainer, you might think. Your Lordships may ask where these care homes might come from, but most trusts have obsolete stock that could be rescued, and what about the homes that private providers may vacate? It would need a little capital, but the potential rewards are enormous.
What about those isolated mental health services? At the moment they are far from providing the equity of esteem with physical illness services that everyone talks about. Would they not stand a better chance if they were more joined up with other health services?
There are two other elements in this brave new world that I should touch on briefly. First, why do patients who need to be checked up from time to time by their consultant always have to spend hours travelling to and from the hospital and waiting to be seen? Consultants and patients have telephones, for heaven’s sake. We could do much more if we could get round the tariff system that rewards hospital trusts for out-patient visits but not for telephone calls. The noble Lord, Lord Prior, and I have discussed this before. We are making nowhere near enough use of IT, the internet, remote monitoring devices built into vests and so on. Patients deserve much better.
The other area I should briefly mention is medical research. I should express my interest here as scientific adviser to the Association of Medical Research Charities, which puts around £1.3 billion a year into research. Research should underpin our integrated NHS, and we must take advantage of our excellent basic research capacity and link it with our unrivalled access to the whole NHS population. It is worth remembering that about 50% of our increasing lifespan is the result of advances gained from research.
I suspect that noble Lords will have noticed that much of the full integration I have described requires local authorities and hospital trusts to agree to a single management system and, where possible, a merged budget. That is something that has eluded successive Governments for ever, it seems. What about the idea of patients being given their own personal budgets, which could ease the transition? Perhaps the Minister could say where we have got to with that.
It is not difficult to see why there is resistance. Social services and GPs are reluctant because they see their precious limited resources being used to prop up the hospitals, while the hospitals have historically seen themselves as providers of acute care and only reluctantly as having a responsibility to the community. It does not help when both are financially squeezed. So is it an impossible dream? It seems to me that we do now have an opportunity to go some way along that route, with increasing recognition by all parties that they cannot go on as they are. It will be difficult, but I did not just dream up these ideas.
We have had excellent example of good practice around the country in Torbay and a number of other places for ever, it seems. But most of my ideas have emanated from Salford Royal Hospital, where David Dalton, its chief executive, has already set up much of this integration and has agreement for more. Here I must admit to some pride in speaking about that hospital, because it is where I spent most of my working life as a professor and consultant. It used to be called Hope Hospital, and has obviously taken advantage of my leaving to do great things.
The hospital trust has been employing its own health visitors for some time. It even has two general practices in its employ, one providing out-of-hours services and the other with responsibility for looking after all the residents of care homes in Salford—both in addition to their normal practice.
Incidentally, all 49 of the other general practices in Salford are linked into the hospital’s electronic case records system. The hospital is now virtually paperless, and GPs and hospital staff have access to all the clinical information about their patients wherever they are. From April this year, agreement has been reached between the trust and the local authority that adult social care, including domiciliary and residential care, will come under the trust’s management with a merged budget—remarkable. Perhaps equally exciting is the fact that the mental health trust will in April be contracted through the new single integrated care organisation, a chance to see much better cohesion between mental and other services.
Salford Royal no longer sees itself as simply a hospital but as part of the community for which it provides for the health and care of all of Salford’s 250,000 residents. All those remarkable developments have been possible only because of inspired leadership in both the trust and the local authority, and it has taken many years of patient negotiation between them, and much legwork with the GPs. Salford is of course a nice, circumscribed, if deprived city which sees itself as progressive, and it has the big advantage of having just one CCG.
None of that has required another health Bill to reorganise or, as Ray Tallis has put it, to redisorganise the service. I have lived through no fewer than eight NHS Bills during my 16 years in this House; that is one every two years, and we certainly do not need any more. I have spoken about the Salford experience because that is what I know best, and it may well not be replicable everywhere else, but Sir David Dalton’s report for the Government of a year ago presented a series of different ways in which closer integration has been able to occur. It does not have to be the hospital trust that manages the budget. It could, for example, be some form of unified joint management system. Much more important is inspired and inspiring leadership—not available everywhere, I fear. It has been that leadership that has produced the essential elements of team-working together, with all members feeling appreciated for doing a good job. That is something that the Government could take to heart.
We have heard about the 25 so-called integration pioneers that NHS England talked about last year. Can the Minister update us on them, and on the pilot schemes in east London announced recently? Then there is the much heralded devolution of budget to Greater Manchester, of which Salford is of course an important part. That is clearly the route that the Government want to take, but therein lies the rub. First, in devolving responsibility, the Government get themselves off the hook if things go wrong. That is what devolution means.
Secondly, merging two inadequate budgets by itself may improve efficiency but is unlikely to be sufficient. It would be a huge blow to the Government’s devolution agenda if Greater Manchester failed for lack of funds. It would mean a big step back for the integration that we desperately need and would put off anyone else thinking of taking the same route. It is inevitable that money must come into it, and, to their credit, the Government have recognised that and have now agreed to provide transitional funding for Greater Manchester of £450 million over four years—just over £100 million a year. Whether that will be sufficient remains to be seen, but it is undoubtedly helpful and should be welcomed.
Although it is good to know that the Government are aware of the need for some temporary funding, there remains the more serious, longer term sustainability of the NHS and, in particular, social care. Almost everyone recognises that the UK spends one of the smallest proportions of GDP on health of almost all European countries: about 6.5% of GDP, compared to an average within the EU of about 9% or 10%. Social service funding is even worse off. All of that is in the face of increasing demand from an ageing population and a frightening increase in the number of patients with dementia. Almost every day we read in the papers of yet another failure or crisis.
We can become more efficient, and I have tried to indicate one way that we might be able to do just that, but short-term injections will not be the solution. We must find a way to provide a more sustainable level of funding to bring our services up to the standards of our neighbours in Europe. It is true, as Mark Britnell describes in his book, In Search of the Perfect Health System, that nowhere in the world has a perfect system, and many Governments struggle. But that is no excuse for starving our own service and having to accept an increasingly inadequate level of health and social care. If we are to gain the advantages of integration that we can clearly see in a few places, we must have the sustainable resources to do it. Of course, there is a separate debate to be had about how we fund our health services, which is something for cross-party discussions, royal commissions and so on, and I do not want to get into it today, although I suspect that other noble Lords may do so.
Meanwhile, the Government must get into the habit of valuing their staff and not blaming them; they must try to show that they are supporting and not confronting nurses and doctors all the time. I am sorry to end, as I started, by decrying the low level of government funding and criticising their attitude to NHS staff, but I do so only against the background I described of what it is possible to achieve by an efficient system of integration. Mark Britnell in his book finds that the most important reason why people are proud to be British is the NHS. Its fairness and accessibility to everyone, regardless of ability to pay is a precious resource, and we must not let it fail.
Lord Turnberg
My Lords, it has been a fascinating debate and I am grateful to all speakers who have participated in it. It is amazing how much information people can pack into three minutes. It has been very helpful. I was bowled over by the maiden speech of the noble Baroness, Lady Watkins.
There is no way in which I can summarise the debate in no time at all but one or two themes have emerged. Everyone agrees that we should focus to a greater extent on prevention. That makes it seem even more ridiculous that we are cutting funding for public health at this time. Most people agree that there is a need to integrate services across the social care/hospital divide, and most people feel that we should begin to appreciate our staff to a much greater extent than we do. To alienate them at a time when we need them so desperately is counterproductive.
On the point that we are seeing a rise in demand and the costs of healthcare, I detected more than a hint from the noble Lord, Lord Prior, that he might believe that the spreading of good practice—there is all sorts of good practice around—and increasing efficiency will solve the funding crisis. I suspect he is the only speaker in the debate, on either side of the House, who believes that. It focused the minds of most people on how we fund the gap.
If one thing has come out of this debate it is that we have begun to think about how—
The Deputy Speaker (Baroness Stedman-Scott) (Con)
My Lords, the time allotted for this debate has now elapsed. I must now put the question that this Motion be agreed to.
Pregnancy: Neural Tube Defects
Lord Turnberg Excerpts(8 years, 6 months ago)
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Lord Prior of Brampton
My Lords, when my noble friend says that this House is almost unanimously agreed she may well be right. However, the decision on this matter has to be taken in the other House. As I said, my honourable friend Jane Ellison, the Minister for Public Health, is going to come to a decision very quickly.
Lord Turnberg (Lab)
My Lords, we seem to have been for ever on this particular question. There is an irrational fear that somehow it is dangerous to fortify flour, and this has held up people in some way or other. But scientifically that does not bear fruit. It is clear from all the experience around the world of many years of fortifying flour with folic acid that it does work. We should be doing it here now.
Lord Prior of Brampton
My Lords, I am certainly not going to argue on clinical grounds with the noble Lord, who knows far more about this than I do. However, the issues are not purely clinical; they are to do with the mass medication of the whole population to reach a very small minority of women of child-bearing age. There are also some administrative issues to do with making sure that people do not take too much folic acid, as some cereals have folic acid added to them. However, I understand exactly what the noble Lord is saying, and can only repeat that the Minister for Public Health is reviewing this now.
Residential Care: Cost Cap
Lord Turnberg Excerpts(8 years, 6 months ago)
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Lord Turnberg (Lab)
My Lords, I, too, am grateful to my noble friend Lady Wheeler for introducing this debate and pointing out so clearly all the difficulties we face. It is difficult not to be gloomy and I am afraid I shall not lift the gloom. Way back in 2011, we had a harbinger of what might happen to care homes when Southern Cross failed with the loss of a large number of beds. Local authorities, which are mandated to care for their needy citizens, were left to pick up the problems; they cannot refuse to do so. Now we are starting to see more of the same, as other large providers of care homes get into difficulties. The latest is Four Seasons, as we have heard, which finds that offering this type of care is increasingly non-viable financially. As my noble friend Lady Wheeler said, it is already in considerable debt, as has been laid out in stark terms in the Financial Times. We could see the loss of many more beds and Four Seasons is unlikely to be the only one so affected.
It is not difficult to see how we have got into this situation. Government funding for local authorities has been severely squeezed and the impact is clear. Since 2010 there has been a fall of 25% in the number of people receiving social care, and the fees that care homes receive from local authorities are strictly constrained. To add to their problems, they are now faced with having to pay their staff the new living wage. Quite right, so they should—these staff have been disgracefully underpaid for the critically important work that they do—but it will cost the sector some £2.3 billion over the next four years. The net result is that care home providers are hit with the double whammy of increased costs and limited income. It is little wonder that they cannot break even. Private domiciliary care providers such as Allied Health have found themselves having to face up to the extra costs due to an EU directive obliging them to pay for journey times to and from domiciliary visits, when hitherto they have been able to get away with it.
It is not only on the supply side that there are difficulties; the demand side is difficult, too. Since 2009-10, the over-75s have increased by about 500,000, a 9.5% increase. It is not simply the increase in numbers that is problematic; the elderly are living longer with disabilities. It does not help to know that in the UK the time between the onset of disability and death is now seven years. That is seven years of dependency. That compares very unfavourably with Norway, where people suffer only two years in need of support before they die.
Of course, many of the causes of dependency lie outside the remit of the Department of Health, but public health clearly does not. While lip service is paid to prevention in all the health plans that one reads about, it is sad to discover that funding for public health is to be cut—by something like £800,000, I am told. That seems an extraordinary thing to be doing when we are trying to reduce the burden of disease. I well understand that it would be difficult for the Minister to change Treasury plans, but is there anything he can do to suggest that it would mitigate the impact on public health?
All this is leaving local authorities and hospital services to pick up the tab, and neither is in a good position to do so. The fall in government support for local authorities is supposed to be bridged by permission to increase their council tax by an extra 2% a year, over the 2% that they already have the flexibility to raise, for the next four years. However, to raise a total of 4% a year across the country consistently for several years is a difficult ask, and it will be much more difficult in poorer areas of the country.
As we have heard, they will have access to the better care fund, money transferred across from the NHS, but they will not receive much, if any, for the next two years. By 2021 they will get about £1.5 billion, and it is interesting that this transfer just about matches the extra that the NHS is due to get. So there is not much relief for the next two years. Local authorities will inevitably have to raid other budgets—but they will already have been doing so for some time, and there is little slack left in the system.
I did not want to talk about the hospital sector in this debate, but it is hard not to when we know that some 30% of beds are occupied by patients who do not need to be there. Everyone knows that. If nursing homes start closing, more patients will be admitted unnecessarily to a place quite unsuited to their needs, and there they will stay for far too long. It is certainly true that the NHS received a very welcome boost in the recent CSR. We should not look this gift horse in the mouth as it is sorely needed, but I fear that it will be only a temporary relief. As the noble Lord, Lord Lansley, said, we desperately need a more basic change in the way that we provide health and social care. It seems inevitable that we will move much more rapidly to a joined-up health and social care system, the fully integrated service that is talked about so glibly. I am not sure that it will necessarily save money—indeed, it may even cost more to get it off the ground—but that must be the way to go for the patients.
Here and there across the country, efforts are being made by innovative and dedicated managers to do just that, but they are having to operate against the grain of the bureaucracy that we have set up centrally. What progress has been made since David Dalton’s report to smooth the path to integration by government, and can we expect a more rapid uptake locally? It will not solve all the problems we face—I fear that more funding for social care by one means or another will inevitably be required—but it will go some way to improving the care of a large number of our most vulnerable people who are currently being shipped around or, even worse, being neglected completely.
National Health Service (Licensing and Pricing) (Amendment) Regulations 2015
Lord Turnberg Excerpts(8 years, 6 months ago)
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Lord Warner (Non-Afl)
My Lords, I start by thanking the Minister for his briefing yesterday, which I found very helpful. I also declare a forthcoming interest in that I shall shortly be chairing a short-term commission to consider the approach to commissioning specialised services, which will report next April. That may well, in the light of the debate this evening, have some fairly uncomfortable things to say about the commissioning of these services in today’s financially straitened NHS. It is very difficult to argue technically with the points made by my former noble friend—still my noble friend—the noble Lord, Lord Hunt, about this set of regulations, but in a sense that misses the bigger point raised by the noble Lord, Lord Patel.
I express my sympathy for the Minister. He is, to all intents and purposes, between a rock and a very hard place. He has to operate within the extremely clunky system provided for setting the tariff for specialist services in the Health and Social Care Act 2012—which, if I may say so, is one of the less distinguished pieces of legislation passed by Parliament. Trying to set a tariff using a system of objection thresholds is a somewhat bizarre way of doing it, even by the standards of the 2012 Act. That so-called new transparent system for reconciling the needs of commissioners and providers has clearly not worked. It is very difficult to see it working, not least because we end up leaving the decision on the tariff right up close to the start of the next financial year. If we want a five-year plan for reforming the NHS, that is about the daftest way to go about setting a national tariff. I understand why no one wants to go back to the 2012 Act and revise part of it but it is pretty bizarre, in a fast-changing world, to set the detail of how you negotiate the tariff in primary legislation. That is a fundamental flaw which we are now struggling with, as a result of that legislation. That is why we are getting into this tangle over the technicalities of this set of regulations.
If I was still the Minister trying to set acute hospital tariffs at a time of tight NHS finance and, at the same time, trying to prioritise community health services and mental health—as the Minister rightly suggests people are trying to do—I would probably be doing the same thing as the Minister, stuck as he is with this piece of legislation. I might even, if I was feeling particularly crotchety, go for 75% instead of 66%. But that is the fault of the system we have landed ourselves with, not because of a devious NHS England, devious Ministers or a devious Department of Health. We need to get to a different system. NHS providers have opened up some issues to talk about. It is certainly very difficult, in today’s age, to argue with the idea of a more open-book approach. But it also requires the open-book approach to take place further back down the food chain, before we get close to the beginning of the financial year. That is the only way these specialised services can look ahead.
It is true when I look back on my time as a Minister —this is where I start to part company with the noble Lord, Lord Hunt—that there is a pretty strong track record of the big NHS acute hospital providers having everything their own way. Even when, as a Minister, I said that the commissioner’s view should determine the outcome, those providers went on pushing and pushing, way up to and past the start of the new financial year. Of course, I am not talking about trusts chaired by the noble Lord, Lord Hunt—I am sure nothing like that ever happened in Birmingham. However, let us be clear, that is how some of the big London providers, in particular, behave—not in our second city, of course; heaven forbid.
There is a long history, then, of big providers pushing the envelope on the price for the job and weak commissioners being unable to stand up to them and deal with them. We now move to a situation where that problem must be tackled, and quickly. We can quibble about the technicalities of the way NHS England and Monitor have handled this episode, but it does not get away from the point that the Minister made: at the end of the day, these guys and girls have to make the decision. They have to decide on a canvas that is much bigger than that being painted by the acute hospital sector.
We should be a bit more forgiving towards the Minister on that. It takes a bit of bottle to say that we are going to put more money into community services and give more money and parity of esteem to mental health, even in a difficult financial climate. That means taking some fairly tough decisions about how much of the collective resources you put into acute hospitals and specialised services. This is where commissioning must play its part. It may mean that we want a smaller number of providers for some of those service lines; it may mean that we have to concentrate them.
NHS providers may not have realised that an open-book approach means that we start to find out more about those who are less productive or effective. I hope the Minister will listen to some of those ideas, particularly the points made by the noble Lord, Lord Hunt, at the end of his speech and by the noble Lord, Lord Patel. We have a clunky system and we need to change how we set the tariff if we really want to deliver the vision in the Five Year Forward View. I hope the Minister will respond positively to some of those ideas for a new approach.
Lord Turnberg (Lab)
My Lords, I must first apologise to the Minister for not appearing at his briefing yesterday and for coming late to his initial remarks. That will not stop me speaking, if I may.
The regulations are clearly designed to save money. They have little to do with correcting what is a major underlying defect in the tariff system: the perverse incentives that tariffs have introduced. My noble friend Lord Hunt has dealt pretty well with how the regulations were aimed at raising the threshold at which objections can be raised and, equally importantly, levelling the playing field to allow small providers with limited budgets to have the same voting power as very large teaching hospitals with billion-pound budgets, which provide more than 95% of the service. It is rather like non-league football clubs and those in the Premier League having the same voice in their commercial activities. The problem is that, to get 66% of all organisations, including all the small ones, puts those trusts that provide more than 90% of the service in hock to those who provide less than 10%. So it is not much wonder that the highly specialised hospitals—the Marsden and Great Ormond Street, the Institute of Neurology, the Christie hospital and so on—are voicing strong concerns about the impact on them. Of course, that is why the Government want to shackle them—to keep costs down—but that is at the risk of denying high-quality specialised care to those who need it.
All that has been well rehearsed by my noble friend Lord Hunt and other noble Lords. I really wanted to point out that the regulations do nothing to get round the unintended consequences and perverse incentives of the tariff system, which I raised with the Minister in a previous debate. That system encourages trusts to go down the route of using devices to gain higher incomes and discourages cross-referral between specialists within a hospital when a trust can gain two fees for two referrals from general practice. It discourages consultants from using phone-in follow-up out-patient clinics to save patients the need to travel in to be seen, as a visit to a hospital incurs a higher fee on the tariff. I agree with the noble Lord, Lord Warner, as he rails against the acute hospitals, but I do not necessarily agree with all his solutions.
I support my noble friend’s amendment. The regulations are unwarranted and damage those who provide the vast majority of the service, while doing nothing to get at one of the major defects in the tariff system.
Lord Kakkar (CB)
My Lords, I declare my interest as chairman of University College London Partners, an academic health science centre which has a number of important providers. The Minister made a very important point about the five-year forward view and the need to encourage new models of care working that ensure collaboration beyond institutional boundaries —and, indeed, to go further and look at new models of funding, including those of accountable care organisations. With a view to a potential journey towards more effective commissioning, and therefore more intuitive constructing of a tariff to support general acute services and more specialised services, will the proposals that the Minister brings to the House today aid that journey? Will looking at these regulations in the way proposed help institutions to work more effectively together, recognising the opportunity to look at tariffs that focus on pathways of care rather than individual segments of care, so ensuring the Government’s objective to ensure that valuable resources committed to the provision of healthcare are used most efficiently? There is a recognition that there will have to be greater attention to these matters as we go forward, and every opportunity should be used to ensure that that objective is achieved. One of the most important is the approach to setting the tariff and, therefore, these regulations.
Palliative Care
Lord Turnberg Excerpts(8 years, 8 months ago)
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Lord Turnberg (Lab)
My Lords, I too congratulate the noble Lord, Lord Farmer, for his immaculate timing in having this debate and for his very wise words. There is little doubt that hospices do a wonderful job, and I for one am lost in admiration for the way they go about caring for dying patients. However, hospices care for only about 3% or 4% of dying patients, and more than 50% finish up in acute hospitals. These hospitals often do a very good job, but they have some problems. For one, they have young doctors and nurses who are ill prepared to deal with death. Too often they have not yet gained the confidence which is needed to give the care and compassion which are so vital. On top of that, they have to deal with their own sense of inadequacy when faced with dying patients. It is not easy. It is no help that they are distracted by having to rush around to deal with seriously ill patients and that they have to focus on saving someone’s life rather than helping someone else to die.
None of that is an excuse for the failing standards, and it is not possible to read the ombudsman’s report with any degree of equanimity. Indeed, as someone who has spent much of his life trying to educate medical students and train post-graduates in the proper practice of medicine, I feel deeply ashamed. As an aside, I should say that there is a peculiar fear that giving adequate doses of morphine for pain relief is somehow dangerous. The correct dose of morphine is that which relieves a patient’s pain, and there is no excuse for withholding it when it is needed. I feel some sympathy for Woody Allen, who said, “I don’t mind dying, but I don’t want to be there when it happens”.
Despite the fact that there is absolutely no shortage of guidelines on how to care for the dying, there is still a huge gap between what we can do and know should be done, and what is actually achieved in too many places. First, it is clear that many patients would prefer to die at home, as many have said. It is obvious that too few social services and primary care facilities can cope with the heavy demand that this sort of care puts on them. Hospices at home can be very successful—as they are in several places, as the noble Lord, Lord Farmer, and my noble friend Lord Judd mentioned—but we need to provide more resources to spread that good practice.
Secondly, we must face an obvious lack of the leadership that is needed in hospitals to ensure that palliative care services are provided in a timely and effective way. We need someone with clout to take responsibility to oversee this service, somebody everyone knows and can turn to when needed. Thirdly, we must place much more emphasis on education and training. This is an area of clinical practice which you cannot just pick up as you go along. You need high-quality training by experts, and it is good to see that tomorrow’s Bill emphasises this. Finally, we have to make sure that CCGs, trusts and those with the money take responsibility for these services being funded, delivered and monitored. Are the tariffs for palliative care adequate? Are these services monitored, and by whom? Many questions are being raised in this debate, and we have to answer them if we are to be judged to be a society that cares for its most vulnerable citizens. I very much look forward to the Minister’s response.
NHS: Reform
Lord Turnberg Excerpts(8 years, 11 months ago)
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Lord Turnberg (Lab)
My Lords, I, too, welcome the Statement and many of the things in it. We accept that higher mortality rates at weekends in hospital are unacceptable, so we have to try to think of ways of reducing them. Seven-day working for consultants is just one element. Consultants are important, of course. The Minister is probably aware of Brian Jarman’s publication some years ago which showed that there was an inverse correlation between the number of doctors in a hospital and the mortality rate; that is, a hospital with more doctors had a lower mortality rate. There are lessons to be learned there, especially as we in the UK seem to have fewer doctors per head of population than almost any other OECD country, and fewer beds come to that—so we are starting from a low ebb, and the points made by noble Lords about where we are going to get the extra people from are important.
However, the consultant element is just one part. The noble Baroness, Lady Finlay, made a very good point about the need for radiologists, physiotherapists and pathology laboratories. All the machinery of the hospital has to be there. Equally, there is the whole business of general practice and community care. Primary care at the weekend is poor, by and large; that is one of the major problems. Patients are not getting into hospital until they are in greater extremis, so they are more ill when they get there: then they require more service, and once they are there, they cannot get home because there is no one to see them home. Concentrating on consultants is just one element. What is the Minister’s response?
Lord Prior of Brampton
The noble Lord, Lord Turnberg, knows the situation on the ground as well as anybody in this House and, of course, he and the noble Baroness, Lady Finlay, are absolutely right that this will not be solved just by having more consultants in acute hospitals. We have to look right the way across social care, primary care, community care, mental health care and acute care. We are talking about a system. In many ways, one of the reasons why we find ourselves in the position we find ourselves in today is that we have not had a system for some time. We have deliberately broken up the system for good reason.
I was very much in favour of foundation trusts having their own balance sheet and their own profit and loss account because of increased accountability, but disadvantages have flowed from that. Chief executives in acute hospitals look after their own. They have treated themselves as an island. We are not part of an island. Rebuilding the system will take some time. It is not going to happen tomorrow, and there is no silver bullet. All I can say is that the Government are committed to the five-year forward view, the new models of care and joined-up care. We are committed to experimenting with accountable care organisations, integrated care organisations and all kinds of joined-up models. We are seeing exciting developments in Manchester and possibly, in time to come, in Cornwall and other parts of the country where we will have pooled budgets between social care and healthcare. I am confident that over the next five years we will if not solve these problems, at least go a long way to doing so.
Local Authorities: Public Health Budget
Lord Turnberg Excerpts(8 years, 11 months ago)
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Lord Prior of Brampton
The noble Lord makes a good point that goes considerably broader than the Question. I accept that many of these things are inextricably linked.
Lord Turnberg (Lab)
My Lords, does the noble Lord accept the report from NICE, which showed that investment in public health improves not only the health of individuals but the economy? Can I tempt him to agree that cutting funding by as much as—I think—7.5% is counterproductive in trying to improve the nation’s health?
Lord Prior of Brampton
The noble Lord may be interested to know that the McKinsey institute assessed that the cost of obesity to the British economy was some £46 billion. I am under no illusion about the importance of proper prevention.
National Health Service: Sustainability
Lord Turnberg Excerpts(8 years, 11 months ago)
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Lord Turnberg (Lab)
My Lords, I, too, congratulate the noble Lord, Lord Patel, on introducing this important debate in such a powerful and impressive way. I, too, resonate very much with the idea of a royal commission. Indeed, I suggested it some time ago in a previous debate.
When the noble Earl, Lord Howe, was Health Minister he must have got used to me banging on about the parlous state of NHS finances, so I see no reason why I should not continue that theme with his esteemed successor, the noble Lord, Lord Prior. But I say at the outset that I do not go along with the “black hole” or the “bottomless pit” theory that we will never be able to fund the NHS adequately. The bottomless pit argument is faulty because, while we may not be able to afford everything that everyone wants, we can and should afford what they need. That is, we can afford a service that is widely regarded as satisfactory and which can meet all reasonable expectations at a reasonable level. Indeed, many countries manage to do this very well.
However, it is clear to virtually all observers that we are not in that position now. We are falling behind. I look back to the halcyon days of the previous Labour Government, when, by 2010, we were putting in almost 9% of GDP, we had got rid of the waiting lists, accident and emergency waits were down, GPs could be seen on the same day and patient satisfaction was high. Now we have problems in all those areas. We have cut the share of the national cake from more than 9% to around 7%. I understand the need for austerity measures, but may I ask the Minister: what is the justification for reducing the proportion of GDP spent on health? Bringing the share of GDP up to a reasonable level is something a country with as high a GDP as ours, and more billionaires per square inch, can afford. All the problems due to these stringencies have, of course, been spelt out in reports from the King’s Fund, the Nuffield Trust and the health service managers who are heading for huge deficits this year. I fear that these are just the conditions in which research and innovation are squeezed out. As the scientific adviser of the Association of Medical Research Charities, I find that particularly disheartening.
Of course, I recognise that there are more efficiency gains to be made. I want to provide one or two examples where the system under which the NHS labours is causing a terrible waste of money, and where efficiency has gone out of the window. I have a friend who is a distinguished gastroenterologist and who is desperately trying to do his best for his patients and at the same time save money for the NHS. Here, I must express my interest as a one-time gastroenterologist way back in the dark ages. My friend was trying hard to fulfil one of the major requirements of NHS England—to move much more care out into the community and reduce the cost of hospital care—so he started running out-patient consultations by telephone instead of bringing the patients up to the hospital. That saved them much time and effort, and they loved it. He also knew that the tariff paid by the CCG for each out-patient consultation was around £150, while a telephone or face-time consultation cost £29. That is a considerable saving to the NHS and a win-win situation. However, noble Lords might imagine how that was perceived in his trust. He was called in to meet a middle manager, who told him in no uncertain terms that he must stop this because the trust could not afford to lose the funding that his activities were causing, so he stopped for a while but has reintroduced the practice surreptitiously and is waiting for the trust to call.
My friend also wanted to set up a one-stop clinic for patients needing endoscopies, seeing them in the morning, treating them the same day and giving them their results later the same day. This saved patients waiting 12 weeks for an endoscopy and three more weeks for the results—just what the NHS should be about: efficient, convenient service. But again, the incentives for the trust got in the way. Trusts lose money when patients attend only once instead of three times.
I doubt whether this is a unique phenomenon, and it is a clear result of the disincentives we have set up in the internal market. So long as providers are desperate for funds from purchasers, we will run into this type of problem. So my question for the Minister is: is the internal market broken and counterproductive, and, especially when we are under such financial constraints, would not an integrated budgetary system be more suited to our needs? How do the Government envisage achieving their objectives of integrating community and hospital care, hitting savings targets and improving the care of patients while we have this dysfunctional internal market? The question is not whether we can afford a health service free at the point of delivery but whether we can afford one that is hidebound by disincentives in the way I have described. I look forward to his response.
NHS: Innovation
Lord Turnberg Excerpts(9 years ago)
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Lord Turnberg (Lab)
My Lords, I am very grateful to my noble friend Lord Wills for introducing this debate in his usual eloquent and powerful way and for emphasising the importance of giant cell arteritis, which is such a devastating condition, but potentially treatable if it is diagnosed early enough. It is a particular pleasure to know that the noble Lord, Lord Prior, is at the Dispatch Box for the first time and giving his maiden speech. I know that he is extremely knowledgeable about the NHS, so I am sure he will have no trouble at all in answering all our questions.
The topic of innovation is very close to my heart. How could it not be, as someone who spent his life—rather a long time ago—as an academic physician and constantly tried to innovate in my practice, and who is now scientific adviser to the Association of Medical Research Charities, which produced that very far-sighted document a couple of years ago, Our Vision for Research in the NHS? In that vision, we wanted to see, first, every patient being offered the opportunity to be involved in research, for example in clinical trials. It is clear that most patients want to be involved. Perhaps they know that there is good evidence that patients who are in trials do better than those who are not. Secondly, we wanted research to be embedded in the NHS and every healthcare worker—doctors, nurses and others—to know that they can contribute to research. They should be motivated to engage in understanding the benefits of research for their patients. Thirdly, we wanted the NHS itself—the CCGs and trusts—to ensure that there is a research culture in its organisations.
How far have we come since then? Of course, some things have got better, but I fear that others have become worse. On the positive side, we have a very strong basic science sector. We are very good in the UK at innovation. We punch way above our weight in our research outputs internationally—citation indices, Nobel prizes and the like. We are being overtaken by China and Singapore, and India is coming up fast on the outside, but we are still pretty good.
Also on the positive side is the investment that the Department of Health is putting in through NIHR, under Sally Davies’s direction. The academic health science networks and centres are doing very important work in encouraging clinical research around the country—long may that continue. My first question for the Minister is about what plans the Government have for the longer-term funding of AHSNs. The last Government were rather cagey about that. Then, again on the positive side, we have the Health Research Authority, under Jonathan Montgomery’s chairmanship, which is doing good things in easing the regulatory burden on clinical researchers. There is more rapid approval through ethics committees and through local trust research committees.
However, of particular importance and value has been the rapid licensing of new drugs by the European Medicines Agency and the MHRA. That will prove invaluable in getting drugs through regulation and into practice. Yet too many hurdles still interfere with the uptake of innovations in clinical practice, and there are too many delays before patients begin to gain the benefits of innovation. Some of these were brought out in the Lords Select Committee report on regenerative medicine. I had the privilege of sitting on that committee a year or so ago. The report suggested that, first, funding for research was problematic. We found that although many original discoveries were made in the UK, lack of research funding and in particular venture capital investment prevented us from keeping ahead of the game. Researchers in other countries capitalised on our inventions—a very familiar story. We now hear that funding for universities might be cut back in the Chancellor’s proposed new austerity measures. What assessment have the Government made of the cuts to universities on research outputs, particularly medical research outputs?
Then there is the problem of how we can encourage doctors to engage in research at a time when clinical pressures on them increase all the time. That is certainly true of hospital doctors but even truer of GPs. Here, there is much greater resistance to engage in or contribute to research activities—clinical trials and the like. When I speak to GPs it is very clear why: they are simply rushed off their feet and overwhelmed by their clinical and administrative load. They just do not have the time. Are the Government doing anything to ease that burden? How can they even contemplate seven-day working and at the same time think about research?
The workload of GPs has another effect too. It impinges on their willingness to take up novel treatments as they come along. I am afraid that a natural antipathy to accepting something new is made worse when they do not have the time to even look at the evidence. If we are to achieve our ambitions for research in the NHS we need GPs to be much more involved. Do the Government have any ideas about getting round this serious difficulty?
Then there is the problem of access by researchers to data about patients. Clinical and other data are vital to the research endeavour and, indeed, for good clinical care. However, the care.data fiasco last year put that back far too far. What is being done now to untangle that mess? When will the planned pilot studies take place? What care is being taken to reassure the public and patients that their confidentiality will be protected, while at the same time explaining how vitally important it is that their data are made accessible to legitimate researchers?
Finally, we have the knotty problem of approval for funding of new treatments, particularly those for patients with cancers and rare diseases. These are often very expensive and must go through specialised NICE or NHS England assessment processes. There is the rub, because these are extremely slow and tortuous. Even though drugs may get a licence quickly through the new systems offered by the EMA and MHRA, they must then jump through the hoop of NICE for funding in the NHS. However, NICE can deal with only three of these requests a year and usually takes well over a year to approve any one of them. It is even worse for those drugs that it cannot take on. It can deal with only three; any more it must pass on to be examined by NHS England. Here, they must be considered by no less than seven serial committees—that is, seven committees in series. If you wanted to invent a system to avoid making a decision, then this is it. What can be done in NICE and in particular in NHS England to reduce this bureaucratic nightmare, set up to approve funding of these new treatments? Is there anything that can be done to rationalise the number of committees employed in NHS England that are needed to do this work?
It has been repeatedly stated by Ministers, including the Chancellor and the Prime Minister, that the Government give high priority to research and, in particular, to medical research. Indeed, the Health and Social Care Act made it mandatory for CCGs and trusts to include clinical research in their strategies, but it is equally clear that these ideals are being frustrated. There are other reasons, but funding for the service is going to be important—funding for GPs; funding for expensive drugs; and funding simply for the service—which makes it even harder for it to engage in the research agenda. But it is not just a question of funding, as I have said, and I look forward with interest to the response from the noble Lord, Lord Prior, and wish him well in facing the difficult times ahead.
Health and Social Care (Safety and Quality) Bill
Lord Turnberg Excerpts(9 years, 3 months ago)
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Lord Turnberg (Lab)
My Lords, I hope your Lordships will allow me just one minute. I do not intend to oppose this Bill, but in Committee I expressed some concerns about the possible unintended consequences of Clause 1. In fact, I have withdrawn an amendment I had intended to move that would have tried to mitigate some of these consequences by pointing to a rather better way of avoiding harm to patients by proper education, training and supervision within hospitals and care homes which would lead to a continuing, progressive reduction in harm but without stifling innovation. I withdrew my amendment because I was told that I would cause the Bill to fall and I have no intention of doing that. But I do hope, at least, that the noble Earl will be able to offer some reassurances on the points that I have raised.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, I understand concerns that noble Lords have raised about the Bill potentially stifling innovation and openness. I assure noble Lords that this is in no way the intention of the Bill. Indeed, the Bill does not place any requirements on providers of healthcare and adult social care registered with the Care Quality Commission. This is achieved through regulations and the associated guidance issued by the CQC. My officials have been in contact with the Chief Inspector of Hospitals, who would be very happy to meet noble Lords to discuss the content of the guidance to ensure that the CQC’s approach to inspection supports continuing reductions in avoidable harm, innovation and supervision and training of staff.