Health and Social Care Bill

Lord Winston Excerpts

Monday 27th February 2012 Lords Chamber

[Lord Turnberg]

My Lords, As someone who taught medical students for many years that it is very important to be absolutely open and candid with your patients, and that, if something has gone wrong, to explain it in full to the patients and their relatives—explaining that that is not necessarily an admission of guilt in some way—I am very keen on the sort of sentiment that is being expressed in this amendment. I am particularly keen on the GMC imposing on doctors the duty of being open. I am all behind the sentiments of this amendment. I have some anxiety, though, about how this can be put into law. How can you legislate for someone to be candid? How will it work? How do you know that someone has been candid or not? There is a great deal of subtlety about this candour and about putting it into law as a duty on every occasion. I am slightly apprehensive about the amendment, even though I support everything about the principle.

[Lord Winston]

My Lords, I find it very difficult, as I have said before, to accept or support this kind of amendment, but I strongly believe in candour and I totally support what many noble Lords, including my noble friend Lord Turnberg, have said around the House. However, there are major problems with putting this kind of amendment into legislation, which would make it extremely difficult to be reasonable. There would be real risks of serious psychological harm to quite a lot of patients. One of the last things we want to do is to involve patients in a perceived injustice or perceived negligence which turns out to fail miserably in the courts of law. I have seen that as horribly damaging with patients I had in the past when I was a medical practitioner, which I am of course no longer.

The other issue not adequately dealt with in this amendment is that of time. At what stage is it justified no longer to be candid? Should somebody who, let us say, sees something from that same health authority a year or two later, or three or four, still be candid about what they think may have gone wrong, or where they are not absolutely certain that it has gone wrong? There is a colossal difficulty in trying to enforce this. Far better is the idea of having some kind of code of practice, to which I think my noble friend Lord Turnberg referred, which ought to be acceptable to doctors.

When I was a trainee surgeon, we did innumerable partial gastrectomies. We now know that that operation was really mutilating and totally wrong; it actually resulted in many people losing weight and not being able to hold down a proper diet. Subsequently, of course, peptic ulceration could be treated by a simple antibiotic therapy. Now, at what stage does that treatment become established or a gastrectomy become a negligent operation? These are very difficult things to define, and I urge that we should not write this proposal into law in the way that is proposed.

[Baroness Wheeler]

My Lords, we had a long debate on this very important issue of the duty of candour before the Recess, and I do not intend to take up very much of the House’s time on this amendment by responding to the issues that we covered then, or by repeating our views on why we are concerned that the Government’s current proposal for a contractual duty will not address the need for the huge cultural change in the NHS that has to take place in order to ensure openness and honesty when things go wrong in the care and treatment of patients.

Nevertheless, I hope that the Minister will accept the case for regulations on including the duty of candour in commissioning contracts. We on these Benches emphasise our commitment to trying to help to make the contractual duty work. I therefore place it on record that we welcome the Minister’s reassurance during the previous debate that he will come back to the House on the outcome and actions resulting from the current government consultation on the contractual duty. I also hope that he will be magnanimous in the victory that he had before the Recess in the vote rejecting statutory requirement by standing by his assurances on a future review of the effectiveness of the contractual duty, after an appropriate period, and whether its effectiveness is being held back by the lack of statutory provision. My third hope is that the NHS Commissioning Board will issue clear and strong guidance to assist CCGs in this matter, and I look forward to the Minister’s response.

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[Lord Patel]

My Lords, I support the amendments relating to conflict of interest and I agree that there needs to be something in the Bill. I will give an example to indicate why I believe that more strongly following a seminar that we attended before the Recess. For those noble Lords who were not there, we had a presentation from a GP who told us, first, that he was salaried, and I therefore presume he did not have a standard general medical services contract, and that his salary came from somewhere else—it may well have come from another general practitioner. He said, secondly, that he was involved in commissioning and, thirdly, that the commissioners had found that the provision of some services in his area was not satisfactory or of the quality that they had asked for—particularly, in relation to hand surgery. They therefore set up an independent provider of surgical services, of which the GP was a non-executive director. The conflicts of interest are quite obvious: here is a commissioner who is a salaried doctor, and that raises a question. If the commissioning board is to hold the contracts of primary care providers, will they not include those who have a general medical services contract, or will they include those who are salaried? More and more primary care providers are salaried GPs employed by other practitioners. We therefore also need to clarify who will be asked to be a member of the commissioning group: will it be only those who hold the general medical services contract, or will it be all those who provide primary care services? The conflict of interest here is many-fold, and therefore we need to address how it is to be resolved.

While I was, and still am, very attracted to the amendments of the noble Baroness, Lady Barker, because I had not seen those of the noble Lord, Lord Hunt, the question of sanctions needs to be addressed more clearly. I agree with the noble Lord, Lord Hunt, on the need for this question of sanctions to be clarified so that those who may be involved in conflict know from the very beginning how those sanctions will apply to them.

[Lord Winston]

My Lords, perhaps I may deal very briefly with one area of medicine with which the noble Lord, Lord Patel, and I are particularly familiar. One problem raised is that increasingly general practitioners are doing minor surgical procedures; increasingly in practice, often in groups. I know of one large practice in south-east England, for example, that is now carrying out a procedure called a hysteroscopy, which is an endoscopic or telescopic examination of the inside of the uterus. This is quite a specialised procedure designed to identify cancers of the uterus at an early stage. The problem is that general practitioners may well be able to carry out this procedure somewhat more cheaply than gynaecologists in a practising group. Of course, there is clearly a conflict of interest here, because they may well be in the very practice that is also commissioning this procedure, and a patient might perhaps be wrongly given a particular treatment when a slightly more expensive treatment, done elsewhere, may be more effective and reduce the risk of the cancer.

[Baroness Finlay of Llandaff]

My Lords, this group of amendments and this debate has focused on conflicts of interest. For clinical commissioning groups, conflict of interest will arise where the leaders of the groups have financial interests, but also where private companies which may have separate provider arms competing as a qualified provider are contracted to provide commissioning support. The other area of conflict which has not been addressed is where quality rewards for commissioning are linked to financial performance of clinical commissioning groups. Further, there are cases where local medical committee officers are key officials in a clinical commissioning group.

The clinical commissioning group is meant to represent the constituent practices. Indeed, there have been articles in the press about commissioning support and commissioning support organisations. Many of those have raised alarm among clinicians who have become increasingly concerned by the talk revealed in the press about the profit to be made by commissioning support organisations. There has also been a realisation that profit going to the commissioning support organisations will reduce the amount of money going into the provision of core NHS services at any level—whether in the community or in secondary care and the hospital sector.

Several amendments are tabled here. The amendment in the name of the noble Lord, Lord Hunt, is very comprehensive and deals with an area which the other amendments do not. There is also an amendment, on which my name is the first, regarding conflict of interest. I can see that Amendment 79A is more detailed than the amendment which I have tabled, and therefore goes further and would be better. However, I am concerned that it does not go quite as far as the amendment in the name of the noble Lord, Lord Hunt, and that some of the principles in there need to be incorporated into Amendment 79A if the Government are minded to accept that amendment. We may have to come back to amend the amendment should it be accepted and incorporated.

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I hope that that provides sufficient reassurance to the noble Lord, Lord Warner, that the emphasis on integration is there, but that he will accept that trying to pin down in words what it should look like may be counterproductive. This is not an argument about the Government’s commitment to integration or what we are doing on the ground to achieve it; it is an argument about a specific mechanism designed to achieve it. I think that it is a mechanism that is ill-advised. I hope that the noble Lord will agree to withdraw his amendment.

[Lord Winston]

I have a short question for the Minister because I feel that it is an important issue. Perhaps I may very briefly tell him about something that I learnt of last week. A friend of mine went to a very famous ENT hospital after a month with a fractured nose—

[Noble Lords]

Order!

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[Baroness Northover]

My Lords, the Minister has sat down, so it is for the mover of the amendment to respond.

[Lord Winston]

I am sure that the Minister will want to answer my question because it is not aggressive or political; it is really to find out how this Bill will work. When somebody goes to casualty after a month with a broken nose and complains, “Look, my main problem is the pain in my sinuses which I have had for a long time”, and is told by the doctor when they had already waited six hours, “I’m afraid the sinuses are a different department. You’ll have to make another appointment”, that is a problem with integration. How does the Minister think we might accomplish better integration with this Bill?

[Earl Howe]

It is a very interesting question from the noble Lord. When I visited Oldham a few weeks ago, I saw for myself how they were getting around that problem in the context of musculoskeletal services. Instead of patients being shunted from pillar to post, they had a system whereby the patient could move seamlessly and immediately from one specialist to another. They did not have to be referred; they could ring up the centre and ask to see a particular person. That is the kind of integrated model that we need to see rolled out more generally in other services. I recognise the issue that the noble Lord raises, but it is one that we are seeing inventive solutions arising to address. I hope that the work being done will do that.

Health and Social Care Bill

Lord Winston Excerpts

Monday 27th February 2012 Lords Chamber

[Baroness Jolly]

My Lords, I had not intended to speak because everything had been said. However, the noble Lord, Lord Walton of Detchant, made a point that I think is worth picking up on. I declare an interest as chairman of the Specialised Healthcare Alliance, which works with people with rare and complex conditions. These conditions are commissioned by the NHS Commissioning Board, while the conditions referred to by the noble Baroness, Lady Finlay, in Amendment 63A are intended to be commissioned by CCGs. Clearly, people are really anxious about these commissioning arrangements. They are based on geography; they are relatively small in number, but not tiny; they are geographically sparse; and very often GPs will not actually see these conditions very frequently.

The noble Lord, Lord Walton, asked whether any thought had been given to sweeping these conditions in with the rare and complex conditions, and to have them commissioned by the NHS board. I am not suggesting whether this is a good or a bad thing, but I think that those with these conditions and the organisations that represent them might be glad to engage in a dialogue on this to see whether it is the appropriate way forward. There is certainly a lot of anxiety about what is currently happening. If my noble friend would give us some indication of whether that could be looked at, that might alleviate some concern.

[Lord Winston]

My Lords, I hope that in summing up the Minister will address the general issue of genetic disease. The noble Lord, Lord Walton, referred to one specific single gene defect but there are some 6,000 single gene defects and they are often very complex. Most of them are fatal diseases and many of them affect children. A few sufferers of single gene defects live to a young age and some occasionally live into middle age. However, one problem that we already find in the health service is that provision for the care, treatment and diagnosis of these patients and for the counselling of their families is often very deficient, depending very much on whether funding is available.

An example is the work that has been going on in pre-implantation genetic diagnosis, which can prevent a child who might die from one of these diseases being born through the selection of a suitable embryo. Of course, this is not a cheap procedure but in terms of financial efficiency for the health service it is very much less expensive than the complex care that might be involved for a child with, for example, advanced male-type muscular dystrophy. Hitherto there has been a huge difficulty in getting these services through individual PCTs because they think in the short term and are on a budget from year to year. Therefore, collaboration seems extremely important not only in relation to these rare cancers, which of course are immensely important, but for a great number of diseases which are extremely distressing. I am sure that the Minister will fully understand and be greatly sympathetic to the fact that the families involved are immensely distressed by these diseases. They are often very puzzled that they may be carrying one of these gene defects and they find it very difficult to get answers to what are quite complex problems. There really does need to be proper provision for them through collaboration with other authorities.

[Lord Turnberg]

My Lords, I should like to comment on Amendment 64ZA. I am sorry to inflict yet another medical opinion on the House but there is one factor which has not been mentioned in the planning of emergency services—that is, the fact that the vast majority of patients in medical wards are admitted through the emergency department, coming in as acute emergencies. This is quite unlike the situation in surgical wards. They, too, have their ration of emergencies but the majority of patients are admitted from waiting lists, and this is where the waiting list initiative and so on come in. However, when planning for medical beds, one has to think in terms of the accident and emergency department being the major route by which these patients enter the hospital and, in planning for emergency services, one has to think of the bed needs associated with that.

NHS: Management Consultants

Lord Winston Excerpts

Monday 13th February 2012 Lords Chamber

[Earl Howe]

Yes, we do, my Lords. Part of the benefit of the modernisation programme will be to streamline the architecture of the NHS so that year by year we will be saving £1.5 billion in administration costs and £3.2 billion net during this Parliament. We need good advice in order to achieve that.

[Lord Winston]

My Lords, the noble Earl said that this Government have spent less on consultants than the previous Government. Does he agree that, perhaps had they spent a bit more, we might have had a Bill that damaged the health service a great deal less?

[Earl Howe]

My Lords, I cannot help observing confused and contradictory messages coming from the Benches opposite. I would be happy to take that advice back to my department.

Health and Social Care Bill

Lord Winston Excerpts

Monday 13th February 2012 Lords Chamber

[Lord Willis of Knaresborough]

My Lords, briefly, I support Amendment 13 in the name of the noble Lord, Lord Patel, and others, particularly on what is behind the amendment. I agree with the noble Lord, Lord Kakkar, that enormous progress has been made since our first debate in Committee where we neared the point of voting through an amendment that would have stymied any discussion on education and training, and I am very grateful that that vote did not take place. However, the reality is that there is a feeling abroad that when you have underqualified providers entering the health space, they will be able to offer services without having to invest in the very important aspects of training.

Given that on the first day of Report the Minister and the Secretary of State agreed to significant amendments about a research-led National Health Service, it is absolutely crucial that whoever takes part in that is able to offer the kind of education and training that enables it to become a reality rather than simply dealing with past techniques. I hope that when the Minister sums up on this group of amendments, and particularly on Amendment 13, he will make absolutely clear what the contractual obligations of other qualified providers will be in order to ensure that the duty placed on the Secretary of State in relation to those who are wholly NHS providers is actually carried through. Will there be a contractual agreement so that they have to agree to education and training, otherwise they will not get a contract?

[Lord Winston]

My Lords, I support what the noble Lord, Lord Kakkar, said about higher education. He talked about the academic health science centres, but they are not what I want to talk about, although I come from Imperial College, which of course has such a centre. My conflict of interest arises possibly as chancellor of Sheffield Hallam University, which has a very big stake in health service education, as I am sure the noble Earl knows. It has one of the most successful schools of radiography in the country, a very large physiotherapy school and an immense nursing school. In particular, of course, the university has very close connections with the University of Sheffield and with health services in the area. The reason for my supporting these amendments is the need to make sure that integration continues in a health service that might become rather more fragmented as more providers come in. It would be helpful if the Minister could address that issue.

[Baroness Emerton]

My Lords, I support the amendments in the name of the noble Lord, Lord Patel, from the point of view of other healthcare professionals—our debate has focused mainly on medical professionals to date. The noble Lord was careful to relate his Amendment 16 to all healthcare professionals. We need to make sure that Health Education England is multiprofessional in its focus. However, the amendment makes no mention of any links with social care. I am aware that we will debate social care in the spring, but it is important that healthcare professionals have included in their programmes and curriculum information on social care.

Amendment 16 mentions workforce planning, which must be a joint exercise between healthcare education and commissioning. The professions will be reassured if they know that workforce planning will be shared between the two rather than it being the concern of health education or commissioning alone. I support wholeheartedly Amendment 13, which encompasses all our discussions and brings to the fore the need for wholeness in healthcare professional education.

Health and Social Care Bill

Lord Winston Excerpts

Monday 7th November 2011 Lords Chamber

The noble Lord, Lord Hunt, asked me about NICE—

[Lord Winston]

I listened carefully to the Minister’s answers to and rebuttals of many of these amendments, which he made with cogent force, and I found it difficult to disagree with them. However, in the case of the amendment of the noble Baroness, Lady Bakewell, I have a problem. The issue of age is such a special case that there is a strong reason to consider writing her amendment into the Bill at this stage, because it is clear from what has happened historically and recently that aged patients are in a particularly difficult situation in an ageing community. They are often not communicated with and left unable to feed themselves, and people are not there to feed them, and so on. The Minister knows all this very well. Is there not a serious case for a caring Government to think seriously about the issues that the noble Baroness has raised?

[Earl Howe]

Of course there is, and I am grateful to the noble Lord. We are anxious to ensure, however, that any measures that we put in place in the outcomes framework are robust in terms of their verifiability. As I have said, I completely agree with the need for good data that have to underpin any system of accountability. I strongly feel that the Bill takes a significant step in the right direction. The NHS Information Centre will be the powerhouse for improving data in the NHS. It will look at how we can improve data for all age groups, not just the over-75s. I take on board what the noble Lord said. If I can add to what I have said, I should be happy to do so in writing.

I shall cover briefly the questions from the noble Lord, Lord Hunt, about NICE. NICE is a body for which we have the highest regard. In the Bill, we are widening its duties and placing it on a much firmer statutory footing. I hope that that in itself will indicate to the noble Lord that, far from downplaying the role of NICE, we want to do the opposite. We are giving it responsibility for defining excellence in social care and for producing a library of quality standards, which it has already started to do. In connection with technology appraisals, we see it continuing to have a very important role. What the noble Lord may have heard on the grapevine, if I can put it that way, related to our plans for value-based pricing of medicines. If we succeed in defining a good system—a good framework—for value-based pricing, the role of NICE will inevitably shift somewhat, because it will be asked a slightly different question from that which it is asked at the moment, but it will retain an absolutely central role, particularly in the pharmacoeconomic evaluation of new medicines.

The noble Lord asked me about the concern that clinical commissioning groups would, as it were, be able to take their own decisions and perhaps disregard NICE guidance. We have made absolutely clear that the funding direction associated with NICE-approved medicines will continue, not only up to the end of 2013, which is when the current pharmaceutical price regulation scheme comes to an end, but thereafter in the new world of value-based pricing.

I agree with the spirit of all the amendments, but I hope that noble Lords will accept from me that they are either not needed or would have an unintended and retrograde effect, which I have tried to outline. I hope that, with that, noble Lords will feel able not to press the amendments.

Health and Social Care Bill

Lord Winston Excerpts

Monday 7th November 2011 Lords Chamber

[Lord Winston]

My Lords, I congratulate the movers of the amendment on the sincerity with which they and the people who supported it spoke. I think that I am going to make myself deeply unpopular both inside and outside this House by saying that I am implacably opposed to the amendment. It is a profound mistake and its wording is quite inadequate and actually very dangerous for patients.

I say this because I have spent some 25 or 30 years of my practice in a secondary referral centre, where I have seen patients from all over the United Kingdom and outside it being referred because they had surgery and other treatments that were botched, mistaken or not properly done and that caused problems. From my serious experience of occasions when I was much younger, telling patients that the thing had not been properly done was often a profound error. It caused immense distress and continued to cause problems afterwards when there was no legal redress possible in any case, as there often is not. By presenting patients to a court, you often add to the distress that might be caused to them and the tensions that they have to go through. The problem with this amendment, good though its intentions are, is that it will increase that risk in the health service.

I do not wish to be anecdotal because I do not think it is appropriate. I could tell numerous anecdotes, rather than just one or two, from a surgeon's perspective to show why I am highly suspicious of this amendment. I will say one thing about why I feel so strongly about this. When you as a doctor give a second opinion on somebody who you believe has been badly treated, there is invariably a degree of subjectivity in your assessment because you are not in the situation that the previous person was in. The amendment refers to,

“any incident or omission in or affecting their care which may have caused harm”.

This is highly dangerous. I believe that it would cause massive problems to a large number of patients and I hope that the noble Lords who tabled it will think seriously before pressing it this evening.

[Lord Mawhinney]

My Lords, I join the noble Lord, Lord Campbell-Savours, as a former Member of Parliament. I am guessing that anyone who was a Member of Parliament for any length of time could, through their constituency casework, repeat the sort of story to which he referred; so I will not burden the Committee by adding similar types of anecdote, other than to say that we cannot all be wrong. Up and down the country, people are going to see their Members of Parliament and saying, “We have a problem that we can’t get past”. There has to be something in the system that is not working right. Like other ex-Members of Parliament, I have from time to time tried to intervene, but the fact that I was a Member of Parliament made virtually no difference whatever to the health authorities. Maybe you would argue that Members of Parliament were the last people they would tell, but they were not going to tell anybody.

Having said that, I also agree with one thing that the noble Lord, Lord Winston, has just said. I hope that the noble Baroness, Lady Masham, will not take this amiss—I will come to my view in a minute—but I do not think that this amendment is the right amendment. Perhaps I may read to her just a few words:

“full information to patients, their carers or representative about any incident or omission”,

that may affect their care. That has been taken to refer to a major problem—a life-threatening problem, a permanent disability or disfigurement problem—but, actually, it could also refer to the numerous stories that appear in our national newspapers, week in and week out, about the absence or inadequacy of nursing care for the elderly. Those are incidents and omissions that affect their care. An amendment that is that wide in its potential scope seems to me to require further thought. It might be described, to use my example, as inadequate nursing care—and, incidentally, I speak as the husband of a qualified nurse—but the nurses do not appear to think that it is inadequate, because it keeps on happening. The management does not think that it is inadequate, because it keeps on happening. The boards of the hospitals do not seem to think that it is inadequate, because it keeps on happening. So, identifying at that level what this amendment might mean seems very difficult.

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[Lord Harris of Haringey]

The experience within the NHS is that people go to law only because they feel that that is the only way in which they are going to get some clarity into what has actually happened.

[Lord Winston]

That is not so.

[Lord Harris of Haringey]

I am sorry; I hear someone behind me saying that that is not so. My experience in my 12 years of leading the national consumer organisation representing patients in the NHS was that that was precisely the circumstance in which many people went to law. They went to law because they wanted to get the information. That was the fact, and I suspect that that is the reality.

[Baroness Hollins]

Perhaps I may raise a couple of issues that have been touched upon. The first is that I do not know how far the consultation that is looking at the duty of candour will tease out the role played by whistleblowing. I should like some clarification about that.

The General Medical Council’s document, Good Medical Practice, in paragraph 31, makes it clear that doctors must be honest and open and act with integrity. I mention that because my noble friend Lord Walton spoke about the GMC’s role and said that he was not sure how far the medical defence unions currently adopt the same approach to encourage doctors, when they are aware of an error, to be open and honest. I decided to telephone my medical defence union before this debate and ask it for its current advice. It said that it refers doctors to Good Medical Practice and reminds them of paragraph 31, which states that they must be honest and open and act with integrity. I hope that the House will be reassured to hear that.

In my experience, a culture of openness and honesty leads to a culture of learning. That point has been made by a number of noble Lords. We should not be afraid of the idea that apologising will in some way lead to a greater culture of litigation. It is certainly my experience that being open and apologising does not necessarily imply negligence; it reflects the fact that something harmful has happened and that the lessons from mistakes must be learnt from in order that other people will not be harmed by the same mistakes in the future. That is what this is really about.

[Lord Winston]

Does the noble Baroness not agree with me, however, that this is not what this is about? The problem is that any persons providing healthcare—someone who is seeing a patient but is not concerned with the original treatment—would be required to be open and candid. The problem with that is that it is likely to be highly dangerous and damaging to patients in that situation, as extensive medical experience over many years has shown to the many people trying to do an honest and open job within the health service. The matters of each case have to be looked at on an individual basis.

[Baroness Hollins]

I absolutely agree with the comment of the noble Lord, Lord Winston. Commenting on another practitioner’s practice and making judgments is fraught with error. That is why it is important when looking at the duty of candour to understand the role that whistleblowing plays. A great deal more could be said but it is extremely dangerous to make assumptions about another person’s practice.

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.

Health and Social Care Bill

Lord Winston Excerpts

Wednesday 12th October 2011 Lords Chamber

[Lord Winston]

My Lords, some three or so weeks ago an 80 year-old lady was admitted to an inner-city hospital in the United Kingdom complaining of abdominal pain. She went to accident and emergency where she had a series of cardiac arrests and was resuscitated on four occasions, according to what I was told. Remarkably, that evening she was still alive in accident and emergency and the following morning she was sitting up in bed talking, not terribly coherently but she was communicating and was capable of asking for a cup of tea. She was still under the surgeons, of course, because she had come in labelled with abdominal pain.

The physicians were concerned about the lady and they did an ECG. They found that her ST segments were elevated and that therefore she may have had a coronary thrombosis, so they phoned Hammersmith Hospital—I have the privilege of being associated with that hospital—because there doctors do thrombolysing. There was some toing and froing about whether she should be admitted there for thrombolysing treatment. Eventually, it was pointed out that on the whole Hammersmith Hospital did not contemplate doing thrombolysing on 80 year-old patients. The patient was left there and eventually she was seen by a surgeon who did an MRI, a CAT scan and various other investigations and decided that the lady possibly had a ruptured diverticulum. The surgeon was not sure whether she was fit to be operated on. In the mean time, an anaesthetist saw her. The anaesthetist said that if the surgeon was prepared to operate, he was prepared to anaesthetise. The surgeon said that if the anaesthetist was prepared to anaesthetise, he was prepared to operate. The lady underwent a laparotomy and the diverticulum was repaired. She spent the next four days in intensive care, where she died an undignified death, which was not what her relatives wanted. They probably would not have wanted her to be resuscitated in the first place.

I tell noble Lords this brief story because it is an example of the lack of co-ordination which is common in the health service, which the noble Earl, Lord Howe, and I have discussed. We both agree that it needs to be improved. Unfortunately, the Bill does not address that issue at all. In fact, one of my concerns is that the fragmentation may actually make the situation much worse. Co-ordination was addressed by the noble Lord, Lord Tugendhat, yesterday, speaking as chairman of the Imperial College Healthcare NHS Trust. He argued that we need to close hospitals. I agree but it will not be easy to do that under the Bill. However, the noble Lord did not come entirely clean—unfortunately, he is not in his place this morning—and point out that the Hammersmith Hospital’s former trust—now the Imperial College trust—is, I believe, some £50 million in deficit this year. There is clearly an urgent need there although, unlike the noble Lord, Lord Campbell of Alloway, I do not believe that the NHS is in crisis.

To illustrate that point, I went to an independent think tank, the Commonwealth Fund, an American organisation which looks at healthcare around the world, and looked at some of its statistics. It turns out that at the end of the previous Labour Government we spent two and a half times less on healthcare than they do in the United States, 18 per cent less than they do in France and more than 40 per cent less than they do in Germany or Holland. It is interesting, therefore, to look at one issue which is really serious for us; the rising problem of ageing in the health service. I chose to look at their statistics for two operations associated with ageing; hip replacement and knee replacement. A knee replacement in the UK costs half what it costs in the US, is 10 per cent or 15 per cent cheaper than in Italy or France and costs 30 per cent less than it costs in Germany. A hip replacement is three times cheaper on the public purse in the United Kingdom than in the US. Do we therefore do fewer operations? Actually not. In the US they do 64 knee replacements per 100,000 of the population compared with 137 in the UK, 121 in Germany and 95 in France. With hips, Germany tops the league with 258 operations per 100,000; France does 208; we do just under 200; Italy, 141 and the United States, 139.

So actually the legacy of the previous Government which we keep hearing about might be a bit better than has been suggested by the present Government. We have heard a great deal about that legacy, but actually, the health service was left in a pretty fine state. I agree completely with what the noble Earl, Lord Howe, said yesterday about outcomes. Of course, it is pointless doing lots of hip operations unless we can match our outcomes with Europe. The figures are not available for those things, but the Commonwealth Fund addressed some interesting issues. Of course, as the Prime Minister said, we have to do something about the health service, but I am not sure that the figures of an independent, international body outside the UK with no political point to make at all can be refuted.

One issue is the satisfaction and the level of successful care recorded by the Commonwealth Fund. I have some figures here to show that the United Kingdom does incredibly well. For an expenditure of something like one-third of that of the United States, in every score we do better than the United States, better than New Zealand, about as well as Holland, much better than Germany, much better than Canada and much better than Australia—typical OECD countries which are rather similar to ourselves. The only place where we failed was in something which the noble Earl, Lord Howe, addressed in his speech yesterday. In the third or fourth paragraph of his speech, he talked about the need to extend longevity. The issue of longevity was clearly described recently by my noble friend Lord Darzi, not in the Chamber yesterday, but in a speech I heard him give at Imperial College last week. He showed a London Tube map from South Kensington, where Imperial College is situated, through Westminster towards Canning Town and in those seven miles longevity drops by seven years. So your expectancy of life in South Kensington, if you are a male, is around 77 and in Canning Town it is about 70. That has nothing to do with the health service; it has to do with education, with the environment, with something that the noble Lord, Lord Ribeiro, referred to yesterday—smoking and obesity. Twenty-five per cent of our population have a BMI of greater than 30. That is a very serious issue. We are about the third worst nation in the world after the US and New Zealand.

These things will not be changed by the Bill. In my view the Bill is unnecessary and, I am afraid to say, irresponsible.

Health: Stroke Care

Lord Winston Excerpts

Monday 4th July 2011 Lords Chamber

[Lord Clinton-Davis]

My Lords—

[Lord Winston]

My Lords, various reports show that the mortality for stroke can be as high as 30 per cent. Sadly, in the United Kingdom mortality is higher than almost anywhere else in Europe, although there is great geographical variation all over the world. One of the issues that Professor Peter Rothwell, of the University of Oxford, has pointed out is that speed is the essence of success. Therefore, it is not merely a question of informing patients, but of making certain that the right availability is present in our hospitals. If we do that we can reduce the risk of a further stroke by 80 per cent and probably, as he says, reduce the cost to the National Health Service in primary care by somewhere between £100 million and £200 million annually. Would the Minister be kind enough to explain how that will work in the future of the health service?

[Earl Howe]

My Lords, the noble Lord is quite right in all that he says. I would just point out that the official statistics are rather historic and it is important that we take stock when the revised figures are before us in some months’ time. As regards how best practice will be driven when the health service reforms are in place, I would repeat my earlier comments about the ability of the NHS commissioning board to drive forward higher quality, informed by the new quality standard produced by NICE. More particularly I think we can do a lot through the tariff. At the moment, best practice tariffs are starting to play a role in encouraging and driving best practice at hospital level.

NHS: Health Improvements

Lord Winston Excerpts

Wednesday 29th June 2011 Lords Chamber

[Earl Howe]

My Lords, my noble friend will know that an independent inquiry into children’s heart services is under way at the moment. It would be inappropriate for me to comment. I have not been involved at all but it would be inappropriate for Ministers to become involved. As regards ambulance and A&E services, we envisage that clinical commissioning groups will commission the great majority of NHS services for their patients, including urgent and emergency care and ambulance services. Prior to that, PCT clusters, which are being formed from the primary care trusts, will be responsible for commissioning ambulance services until 1 April 2013.

[Lord Winston]

My Lords, does the Minister agree that we are facing one of the greatest revolutions in medicine—that is, genomic medicine? It will make medical treatment more effective and efficient and will reduce the national drug bill. Therefore, does he not agree that one of the most urgent needs of a large population is for increased computing power and proper information technology?

[Earl Howe]

I absolutely agree with the noble Lord. The information agenda, which should run in parallel with our plans, is essential for delivering the improvement in outcomes that we all want to see. Part of that will involve new technology. As the noble Lord knows, work is under way on genomic medicine, which is extremely exciting. We have included in the amendments tabled to the Health and Social Care Bill in another place a duty on both the Secretary of State and clinical commissioning groups to promote research in the health service.