Health and Social Care Bill

Lord Winston Excerpts

Tuesday 25th October 2011 Lords Chamber

[Lord Ribeiro]

The noble Baroness makes her case but there is a wide spectrum of medical provision, and the question is whether this could be applied to every single provider. I am not clear about that but perhaps the Minister will be able to address it.

Returning to the question of training, I believe that through the Bill there is an opportunity, perhaps when the contracts for some of the independent sector treatment centres are up for renewal, to give some serious thought to whether these centres could provide the extra capacity that the NHS desperately needs if it is to go forward with the functional separation of emergency and elective care. I am of course talking about surgery and I recognise that that is a special case. None the less, we come from a history of one type of surgical provision to the situation in this Bill. If we are talking about quality as the indicator of the outcomes that we are looking for, it may well be possible to achieve this by utilising the ISTCs for NHS consultants. I shall give way if the noble Lord wishes to speak.

[Lord Winston]

I had no intention of interrupting the noble Lord. I merely thought that he was concluding his remarks and I was going to follow.

[Lord Ribeiro]

I take the distinct hint that it is time to conclude my remarks. I merely wish to say that we have an amendment in the Government’s name. It may well have been prompted by noble Lords introducing their own amendment, but the fact is that it is now there in the Bill.

[Lord Winston]

My Lords, I was interested to hear that the noble Lord, Lord Ribeiro, thought that the Chamber was full of doctors. I suspect that if we were discussing a legal matter, it would be full of lawyers, or if it was a matter relating to the City, it would be full of industrialists and so on. It depends on the nature of the Bill. It is very good that the Chamber is currently full of doctors because, like the noble Lord, Lord Ribeiro, we can give special credibility to the discussions and amendments that we are trying to tease out. It is a pity that there are not more members of the nursing profession in the Chamber, as well as others who are involved with healthcare and its wider applications.

[Noble Lords]

Hear, hear!

[Lord Winston]

Perhaps I may be permitted to tell a very minor story. In the 1960s, I was in an NHS teaching hospital out in the sticks of Essex. It was certainly not a university hospital. I was a junior registrar in training and I had been supervised pretty carefully by a remarkable surgical colleague in his sixties, Mr Sandy Crawford, who was my consultant. One night, I rang him up at about two o’clock in the morning. It was a very cold night and it was snowing. I said, “I think this woman needs an emergency caesarean section”. At the other end of the phone came the reply, “Eh, Robert, do you think you’d like to do it?”. I said, “Well, I’ve not done a caesarean section without supervision before”. He said, “Why don’t I just come in and sit in the surgeon’s changing room while you’re doing the operation. You carry on and I’ll drive in”. That is what he did. When we had done the operation, which went perfectly smoothly, and delivered the baby, at about four in the morning he poked his head round the door of the theatre and asked, “Robert, is everything all right?”. I said that it was and he said, “Do you think I could go home now?”.I told him that he could. The following morning I told him that I thought it was very good of him to have come in to supervise me in that way. He said, “Training, which I think is important, is part of my responsibility as a member of the National Health Service”.

I think that here we are talking about the ethos of the Bill, as was the case with the previous amendment. I had some problems with that amendment because I felt that the Minister had demolished some of the arguments very well. However, here the issue is different. The noble Lords, Lord Walton and Lord Patel, have made very powerful points about absolutely embedding training in the Bill. That is of increasing concern, as the health service may become more fragmented and any willing provider may end up doing surgical procedures such as the ones on which I learnt. I am sure that the noble Lord, Lord Ribeiro, will agree. Doing a routine hernia, for example, within an academic environment was of great advantage to me, as I was able to learn how to operate and handle tissues in a general way for other procedures. One problem is that, because it is more efficient, willing providers may end up streamlining those sorts of procedures outside an academic environment, and that training experience will be lost.

I have worked in America, Belgium, Australia and one or two other countries. I spent a year in Belgium. I can tell your Lordships that the training, and commitment to training, in some of those other countries is quite different. We recognise that we have something rather special and unique in the academic environment in this country. In fact, it is not just two jobs that we do as consultants; in my view, it is four jobs. They include delivering the best possible clinical care that we can, but there is also the question of doing research in the academic environment, which is quite different. I know that the Minister agrees that we need more clinical research to improve the translational element which is so critical in our National Health Service, but there are two other areas which are different in many ways. One is teaching, which is different from training. Training is the ability, for example, to take a surgeon through a procedure and learn not to interfere when he or she might be making a minor error which will not damage the patient in any way or jeopardise the patient’s care. In my view, that requires a different kind of judgment compared with training someone in the scientific basis of a procedure or the physiology of the patient undergoing the pathological condition.

At the heart of this is an issue which was briefly touched on by my noble friend Lord Turnberg. One concern is clearly how we appoint people to the health service—particularly nurses and doctors. If we have that ethos, which is stated clearly on the front of the Bill and very solidly within the Bill, we must have in mind that in appointing new people to the health service we must consider not merely their ability to do the job well but how they communicate skills. It is widely felt by the public that sometimes many of those aspects of communication are not well served, both in teaching and in communicating with patients. I hope that the Minister will agree that there is a very strong case for considering the points that have been raised by those in whose names these amendments stand.

--- Later in debate ---

[Earl Howe]

It did happen, but it did not happen with the system that I have outlined in place. As I have just said, NHS Future Forum is talking to a great many people about where exactly responsibilities should sit for what, and how the system should work, which is why—I confess freely—I am in difficulties. While I would love to be able to answer detailed questions about the system, we have quite consciously deferred these matters to a second Bill.

[Lord Winston]

Perhaps I could ask the Minister a general question. The noble Lord has been specific in picking up some of the details of the amendments. The beauty of the amendment proposed by the noble Lords, Lord Patel and Lord Walton, is its simplicity and ethos. Government Amendment 43, proposed by the Minister, refers to the,

“delivery of education and training to persons who are employed, or who are considering becoming employed”,

in the health service. Considering becoming employed can mean a whole range of things. A lot of people who are considering becoming employed in the health service may not actually apply for a job. How is that possibly enforceable within the context of this amendment?

[Earl Howe]

I am surprised by that criticism because that is designed to capture trainees, who may not have a guaranteed job at the end of the day. If you simply refer to people who are already employed, you surely cut that cohort out of the equation. That is the purpose of those words, and I think they are entirely appropriate.

--- Later in debate ---

[Earl Howe]

I am grateful to my noble friend and, naturally, I will give full consideration to his suggestion. The government amendment represents the fulfilment of our undertaking, made in another place and more publicly, to put clearly in the Bill the Secretary of State’s accountability for an education and training system. That is what we have done. It may be that we can go further in the Bill; I will certainly consider that. Our intentions, as I have enunciated them, are clear, but I come back to saying that we do not want to pre-empt the findings of the Future Forum and the wider consultation that we are engaged in.

[Lord Winston]

I am sorry to interrupt the Minister again, but I find it incredible that we are now in Committee in the second Chamber on this large Bill and the Government are still apparently in the middle of their listening exercise. Does this not argue that the Bill is extraordinarily badly prepared and that these things should have been thrashed out well in advance? Is that not what the noble Baroness, Lady Tonge, was talking about? It is something that will shock people who are listening to this debate.

[Earl Howe]

No, my Lords, that is not the case. I completely reject not only that remark but also the remark of the noble Lord, Lord Davies of Stamford. Our plans for education and training have been moving forward ever since the election. The White Paper in July 2010 set out the broad principles underpinning education and training reforms. A consultation paper was then published in December last year, with the consultation finishing in March of this year. The Future Forum then listened to further views. It recommended the new duty which we are discussing today in the form of Amendment 43, and we accepted that recommendation. Meanwhile, the Future Forum continues to listen to the views of the wide range of stakeholders and its report will feed into future legislation on this topic. We have consciously deferred the meat of this issue to a future Bill, because we have to get it right. We have committed to publishing further proposals on education and training once the Future Forum has concluded its report and there will be a chance for noble Lords and others to feed in at that point if they so wish.