Health and Social Care Bill

Debate between Lord Walton of Detchant and Lord Kakkar

Monday 13th February 2012 Lords Chamber

[Lord Walton of Detchant]

I support the amendment and will make a point about costs. As I said last week in a debate on education and training, since the health service began, the actual financial consequences of training specialists in all branches of medicine—surgeons, physicians, psychiatrists and all other specialists—have been the responsibility of the National Health Service. Many of us will remember the days of SIFT—the service increment for teaching—a financial increment that was given to hospitals and other organisations that provided postgraduate training at the same time as training undergraduate students. I have, I believe, an assurance from the Minister that that process is going to continue, which is extremely welcome. So I am not speaking primarily about finance.

However, I want to raise a point with the Minister that was touched on only superficially in the very helpful debate we had last week where the Minister tabled a series of very important and constructive government amendments and gave a number of very crucial assurances. I particularly want to raise the interrelationship between the health education authority and the regulatory authorities, which has not yet been clarified. The Explanatory Notes mention the importance of Health Education England working with professional regulators. I shall refer to the General Medical Council as an example because I was its president from 1982 to 1989, and before that, for seven years, chairman of its education committee. The fundamental point is that under the Medical Act, the General Medical Council’s education committee has the responsibility of ensuring,

“high standards of medical education and co-ordinating all stages of medical education”.

It is the regulator. If a new medical school is created, it has the authority to inspect it and consider whether its curriculum is sufficient. It has the authority to inspect the qualifying examinations of the medical schools in order to make certain that they are achieving an appropriate standard.

The fundamental point is that the GMC and the other regulators are not just stakeholder groups. Their statutory powers,

“provide independent assurance to patients, the professions and the service that national standards apply across the UK both in terms of the quality of medical training and the outcomes it produces”.

Of course, the important difference here is that Health Education England applies only to England, whereas the GMC and the other regulators are responsible for the oversight of education across the entire United Kingdom. What I seek from the Minister—formally, if I may—is an assurance that the activities of Health Education England will not usurp or attempt to usurp any of the statutory responsibilities of the regulatory authorities, which are already enshrined in law.

[Lord Kakkar]

My Lords, I support Amendment 13 in the name of my noble friend Lord Patel and Amendment 16, which again is in the name of my noble friend and to which I have added my name. This is the first time that I have spoken at the Report stage of the Bill and I remind noble Lords of my entry in the register of interests as professor of surgery at University College London, consultant surgeon to University College London Hospitals NHS Foundation Trust and fellow of the Royal College of Surgeons of England, which is one of the royal colleges that has decided critically to engage with Her Majesty’s Government with regard to the further passage of this Bill through its parliamentary stages.

The reason why there is such anxiety among so many bodies associated with the practice of medicine in our country as regards education and training is in no small part due to the fact that there was terrible trouble and a very unfortunate turn of events associated with the medical training application system—MTAS—some years ago. As a result of that, all those who have some responsibility for education and training are obliged to pay particular attention and scrutiny to any provision concerning the future of education and training for all healthcare professionals in our country.

Amendment 13 in the name of the noble Lord, Lord Patel, is very important. It brings together all those with responsibility for the commissioning and provision of healthcare under a single obligation to respond to the responsibilities of the Secretary of State for Health with regard to the specific question of education and training. There can be no doubt that all those who wish to engage in the provision of a national health service must be alive to their responsibilities in this regard. To have that commitment in the Bill would provide a very important opportunity to allay the considerable anxiety that might exist among the regulatory bodies, such as the General Medical Council, which the noble Lord, Lord Walton, mentioned, and the medical royal colleges to ensure that they have done their duty in terms of protecting a structured process for the delivery of education and training for the entire healthcare workforce.

Amendment 16 is very important because it deals with the establishment of Health Education England. At this stage, it is important to recognise the very proper and constructive way in which the Department of Health, the Secretary of State for Health and the Minister have engaged with the professional bodies with regard to education and training. It has been a remarkable process of discussion, which resulted in the important government-sponsored amendments that we were able to debate last week on the first day of Report and the important recognition that in creating Health Education England there is an obligation to bring together all the resources available for undergraduate training in the healthcare system and for postgraduate education and training.

Is it absolutely the intention that all three funding streams—SIFT, MADEL and MPET—will come together as a single budget for Health Education England at the time of its creation and that that budget will be spent by HEE through local education and training boards to engage a variety of providers at a local level in discharge of responsibilities for education and training in a postgraduate sense and to maintain the additional resources available in clinical environments—primary, secondary and tertiary care—for the continued undergraduate education of our medical and dental students and other healthcare professionals?

It is also important for your Lordships to understand how Health Education England will be composed. What will be the process for appointment to HEE once it is established, potentially first as a Special Health Authority later this year? Will the composition and membership of HEE include representatives from medical royal colleges and other organisations, such as the regulators and so on? Will HEE be responsible for the appointment of the chairs of the local education and training boards? There is particular concern with regard to the need to have independent chairs of local education and training boards. It is vital not only that at the local level these boards have appropriate provider, employer, patient and trainee representation, but also that their deliberations are conducted in a transparent fashion. This can be done only if the chairs are indeed independent of all the interested parties.

There is a further question with regard to the relationship between local education and training boards and the proposed academic health science networks. Do Her Majesty’s Government have a view about that? It is particularly important because a process is ongoing at the moment for the designation of 12 or so additional academic health science networks in the country. Those broad networks will have an opportunity to have substantial employer and provider representation, encompassing universities and NHS providers. It would be useful to understand their potential relationship with local education and training boards. Then there is the question of the future of postgraduate deans. Again, this is a matter of detail, but it is important in understanding how the structure of independent deaneries will work in a future system and, in particular, what relationships the universities will have at the level of provision of local training and education.

I think it is well recognised in your Lordships’ House that the Government have come a very long way on the question of education and training, which is much appreciated, but some further detail is important to allay anxieties and to ensure that the best possible advice, expertise and knowledge can be brought to bear in creating a new system for education and training for the future that does not result in unintended consequences and some of the disastrous outcomes associated with the previous MTAS scheme.

Health and Social Care Bill

Debate between Lord Walton of Detchant and Lord Kakkar

Monday 7th November 2011 Lords Chamber

[Lord Kakkar]

My Lords, I support this group of amendments and in so doing remind your Lordships of my interest as consultant surgeon at University College London Hospitals NHS Foundation Trust, an institution with private healthcare facilities that I would be entitled to use if I ever decided to do so. This group of amendments is very important because it deals with an area of anxiety with regard to potential consequences that will follow removal of the private patient cap. Removing that cap may well provide important opportunities for NHS foundation trusts in the future, opportunities that they may well need to exploit. But in so doing, we need to be certain that access to clinical facilities in NHS institutions for either NHS patients or those in private healthcare facilities in NHS institutions is based purely upon clinical need and that no other factor influences access to those facilities.

I believe that in the majority of circumstances that will always be the case, as it has been to date. But with the important changes in this Bill with regard to the role of potential private practice in NHS institutions, we need to be absolutely certain that any anxieties or opportunities for misunderstanding are dealt with at an early stage. So in bringing forward these amendments at this stage, one hopes that there is an opportunity for the Government to explore how they plan to deal with any potential tensions and what security the current Bill as we consider it, and any potential amendments in the future or well established working practices in the NHS to date, would protect against a situation developing where access to facilities was determined by anything other than absolute clinical priority. For this reason I strongly support the amendments being brought forward at this stage in the hope that the noble Earl might be able to provide some clarity on the approach that Her Majesty’s Government might take in regard to these matters.

[Lord Walton of Detchant]

My Lords, 53 years ago, after seven years in full-time clinical research followed by 18 months as a first assistant in a neurological department with an honorary senior registrar contract, at the age of 35 I was appointed as a consultant in the NHS. But since at the time I had not even reached a salary of £2,000 a year, on being appointed as a consultant I chose to take a maximum part-time contract to do limited private practice, if only for financial reasons. In fact, it was a very interesting experience. I did this only for a few years before I became a full-time academic.

At that time every NHS hospital had a private ward or had the opportunity, as was the case in the regional neurological centre in Newcastle Upon Tyne, such that on my ward of 28 beds I was entitled, if I so wished, to use four single rooms for private patients. The advantage of that arrangement, which was widespread throughout the country, was that the consultants working in that kind of hospital had the right to be geographically whole-time at the hospital. They were not being diverted away to distant private hospitals. They could look after their patients, both private and public, on the same ward and give them equal standards of care. The only real advantage for the private patients was that they had single rooms.

Many years later, along came Barbara Castle, who was the Secretary of State for Health and who later became the much respected Lady Castle. By that time I was a full-time academic with no private practice. I took private patients under my care into hospital, as I had to do if they came from overseas. In order to take advantage of the research facilities in my department, they had to be treated as private patients. However, under pressure from the trade unions, the Government worked through a process of gradually removing private patient beds from NHS hospitals so that, in the end, in the three major hospitals in Newcastle Upon Tyne we had one private bed in each hospital. The result was that, as an academic with major research facilities for the investigation of neuromuscular disease, I had to refuse patients referred to me from the United States, Canada, Australia and elsewhere because there were no private hospitals which could provide the facilities needed for the investigation of these patients, and there were no private beds into which they could be admitted. I look back on the period before that, when there were private beds in NHS hospitals, with great interest. I think that it was an excellent arrangement.

This is why I strongly support the proposal that the cap on private patient beds in NHS hospitals, foundation trusts and so on be removed, but I agree that there should be a restriction so that the opportunity for such beds to be established for private patient care must not be excessive. However, the advantage is that the NHS will gain substantially from the income derived from those private beds. The noble Lord, Lord Phillips, has enunciated the principle that the standards of clinical care for public and private patients in those hospitals should be entirely comparable. The only advantage for private patients would be a better standard of accommodation, as Amendment 299B indicates, which is wholly acceptable. The quality of medical care should be identical. For that reason, I support the principle.

On the other hand, the wording of Amendment 30 is not satisfactory. Although I accept the principle of equal standards of clinical care, the amendment would make it impossible to provide the improved standards of accommodation to which Amendment 299B refers. The principle is important and I would support it in general, but the amendment needs a little adjustment.