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.

--- Later in debate ---

[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.

Public Bodies Bill [HL]

Lord Winston Excerpts

Monday 9th May 2011 Lords Chamber

[Lord Willis of Knaresborough]

I rise to speak specifically in support of Amendment 9, to which I have added my name. However, I want first to record my thanks to the noble Earl, Lord Howe, on the Front Bench for the very courteous way in which he has tried to respond to these issues throughout the passage of the Bill. The reality is that we should not be at this particular juncture now. If we had had proper consultation before these proposals came to light, we would have been able to argue the issues out sensibly and carefully. I recall the way the last Government treated the draft tissue and embryo Bill. They created a committee of both Houses that looked carefully at the issues and prepared a report. It was accepted by them and actually changed the legislation that was going through the House. With hindsight, we can always do things differently, as we learnt last Thursday.

I think that Amendment 9 is crucial. The Academy of Medical Sciences made a proposal to create a health research agency that was not just supported by the medical and research professions, but by all the political aspects of all the parties in both Houses of Parliament. It is rare for that to occur. I have argued with the Minister that the real crux of this Bill is not knowing what you are actually going to move to. I think that the concerns about the CQC are a little unfair. The reality of the situation is that the CQC already regulates and inspects a significant number of premises and establishments that deal with the use of embryos, embryo research and the clinical application of techniques using embryos. There is already significant duplication, so to argue that a new body would either increase or decrease duplication would depend on how you finally decide which functions will go to which organisation.

Health research is also crucial. The report of the noble Baroness, Lady Warnock, has rightly been mentioned often today. She established firmly back in the 1980s the fundamental issue of the special nature of the embryo, particularly when dealing with research. The noble Baroness, Lady Deech, is absolutely right that the founding of the HFEA has enabled research using the embryo, particularly when we started to look at stem cells and admixed hybrid embryos, to go through. That is because there has been a regulatory authority for which there has been public as well as clinical and academic support. We throw that away at our peril.

I put it to the Minister in Committee that we could not move to an interim authority for health regulatory research and believe that we could maintain continuity and credibility within the research communities both here and abroad. Unless we establish the health research agency, we will lose ground. It is too important an area for us simply to say, “Well, we'll wait and see’. In his incredibly helpful letter to the noble Baroness, Lady Thornton, the Minister referred to setting up an interim authority. However, in Committee, I proposed to my noble friend that a new clause be inserted in the Health and Social Care Bill to set up the paving legislation for the new regulatory research agency. My noble friend makes it clear in his letter to the noble Baroness that that Bill is now on hold for a while for a variety of reasons. Surely this is an excellent opportunity for the draftsmen to put into that Bill a clause which enables the agency to be set up. At one fell swoop, an early place in the legislative timetable—literally within the next six months could be given to an agency that all of us agree needs to be in place. Amendment 9 offers the Minister the opportunity to respond positively today and we could go ahead with those proposals.

The second part of Amendment 9 deals with the incredibly important business of an ethics committee. Many people who are not involved in the ethical consideration of these issues believe that this is somehow a sop or an add-on. It is not; it is fundamental to maintaining confidence in the research frameworks and the regulatory authorities. I hope that when my noble friend the Minister responds to the amendment he will give us clear direction on how the new agency will have an ethics organisation which meets the aspirations not only of this House but of the research and clinical communities.

[Lord Winston]

My Lords, I have not decided whether I shall vote for or against the amendment if it is pressed. I shall listen very carefully to the Minister’s response.

One of the greatest ethical issues involved in this treatment is its lack of accessibility. It is a highly privileged treatment, because it is mostly in the private sector. It is true that the NHS provides some, but many health authorities have based their fees to some extent on the private sector. Therefore, the hard-pressed PCTs have not been able to offer as many treatments as many people recommend.

When I left practice running a large IVF clinic some five or six years ago, we were charging very much less than is currently charged by clinics. We were still able to turn more than £1 million a year over to research and provide the Hammersmith Hospital with a great deal of surplus income, which was then used to treat other patients.

One of the key issues with which the HFEA has not dealt is the high cost of IVF treatment. In my view, it is a scandal. There are clinics that treat patients for around £3,400 a cycle. It is only when you look at their websites that you see that they are charging up to £1,100 to £3,200 for drugs that should be obtained on contracts at around £500 to £700 per cycle. Embryo freezing will be increasingly required if we are to limit the number of pregnancies that result in multiple births by transferring just one embryo each time. One clinic in London charges £915 for embryo freezing. That is for a mechanised treatment that is extremely easy to do in the laboratory. If that were not enough, the storage fees are £325 a year. Given that liquid nitrogen, which is what the embryos are stored in, costs a few pence a litre, that seems somewhat excessive, even allowing for the costs of regulation. I am afraid that the HFEA has shown itself to be completely unable to deal with this issue at all. This privileged treatment is a shocking issue.

Secondly, one thing that the HFEA claims to be doing is giving accurate information to patients. This morning, I trawled a few IVF clinic websites. A prominent clinic in London—which I can name but will not—argues on the front page of its website a 69 per cent IVF success rate. That figure is repeated twice on the website. It is only when you delve into the small print that you realise that it is nowhere near that. That is the cumulative success rate over several cycles of treatment. Another clinic argues that it has a 30 per cent success rate in women over 40 or 42. That is a biological impossibility given that the implantation rate alone of a patient under 40 is something around 18 per cent per embryo—at best 25 per cent. What the site does not say is that this is for pregnancy but not delivery of a live baby. It does not take into account the vast number of miscarriages that presumably these patients are going through. This kind of misinformation occurs again and again.

The Bridge fertility clinic offers a 71 per cent pregnancy rate per blastocyst treatment and 67 per cent success rate for pre-implantation genetic diagnosis. As someone who has been intimately involved with pregenetic screening of this kind, I find those figures, frankly, quite incredible. Perhaps they depend on very few patients being treated and a good deal of luck. But that is highly misleading. These treatments have not been validated by the HFEA. Presumably, that is why it has allowed advertising to continue.

Then we come to the ways of promoting treatments that are not acceptable in this country. There are several clinics in London alone that offer their services in, for example, Mauritius—that is one of the Harley Street clinics—the USA, India and Spain. There they can display all sorts of unvalidated success rates on their websites and in addition can offer treatments that are not acceptable in the United Kingdom, such as multiple embryo transfer. Why has the HFEA not withdrawn the licences of those clinics? Why has it not argued that this is dishonest and dangerous?

Then, of course, we have the question of the database, which has been referred to already. The database ought to be very valuable but, sadly, in practice it is useless because we cannot follow up patients in the long term. That is a very serious issue. As the Minister knows, epigenetic issues—early experiences in development from fertilisation onwards—may have a profound effect on our health when we become adults. IVF in this country is not followed up in this way, so we have no way of knowing whether some of the treatments or exposures of the human embryo may be more likely to cause damage at a later date.

Then we have the question of another issue, which the HFEA seems to have been totally powerless to deal with. That is the issue of treatments without any evidence base that they work. Let us take the example of immune therapy, which is charged at anything from £1,000 to £3,000 a time, in addition to the already high fees of IVF. Where is the evidence that immune therapy actually improves the success rate of pregnancies? I do not know of that evidence—and, indeed, the treatment may even be damaging or harmful to the patient’s residual immune system.

Then we have preimplantation genetic testing, which is testing of embryos genetically when IVF has previously failed. I accept that preimplantation genetic diagnosis works, as the noble Lord, Lord Walton, has said, and it is a valuable technique in a few patients. However, there is actually no evidence base showing that preimplantation genetic testing in people who do not have a genetic defect, as widely used by many clinics, provides a helpful and improved chance of a pregnancy afterwards. The control trials and the control evidence are not there, and this treatment—if it is done at all—should be done on a research basis. However, the HFEA has failed to license it on that basis. The same applies to the treatment of assisted hatching. These are not small treatments; preimplantation genetic testing is charged in one clinic at £2,690 in addition to the £3,000 or so charged for the IVF and the £800 to £1,000 for the drugs that the patient pays for. At this stage, patients who are desperate will do anything to ignore the avarice of the people who might be treating them. This is a massive issue, as it is with another treatment, widely offered, of assisted hatching, in which a little piece of damage is done to the zona pellucida around the embryo or egg in the hope that it might improve the pregnancy rate. Over many years it has not been shown to be really effective, but it is still widely sold without any proper regulation.

We have heard from a number of speakers in this debate that the HFEA is the envy of the world. If it is the envy of the world, why has no other jurisdiction accepted this method of regulation? It is not used in Singapore, the USA, France, Israel or Australia, the countries that are most successful at reproductive treatments. I am not suggesting for a moment that we should not have a proper culture of regulation or a proper ethical standard in how we deliver medicine, but the current workings of the Act of Parliament are now not suitable for the original purpose. We have outgrown it. With the burgeoning private practice that has occurred with this treatment as a result of the failure to fund it in the health service, we have an increasing problem, which is very far-reaching.

It is true that there are virtually no good academic units in the United Kingdom that really produce cutting-edge research in the field of reproductive biology where it applies to humans. That was not true 30 or 40 years ago, when we led the world, in places such as Cambridge, London, Edinburgh and many other centres in Scotland. Now we cannot find people to appoint to chairs in reproductive medicine. The chair at Hammersmith was left vacant for three years after my retirement, and eventually they decided not to seek anyone to fill it. They could not find somebody who was a suitable academic because people are being attracted to the highly lucrative business that IVF provides. In my view, this is a very serious problem.

One of the most respected academics in this field is Professor Alison Murdoch, in Newcastle, who has pointed out something really quite interesting. I take her view very seriously as I believe that hers is an example of a really well-run, ethical practice. She points out that regulation of in vitro fertilisation is now far greater than regulation of, for example, abortion. That does not seem to make sense. I listened very carefully to the right reverend prelate the Bishop of Guildford. However, does he really believe that the protection of the embryo is more important than the protection of the foetus or the protection of research on the newborn child, the patient who is pregnant or the elderly patient who may be about to die from various diseases? Surely the notion of centralising our research under one body makes good sense, because we can then have a rational basis for important ethical decisions. I shall listen with great intent to how the Minister responds to this debate. However, I am not convinced that, even if we vote for this amendment, it would be a good idea to vote for the preservation of the HFEA as it stands.

[Lord Patel]

My Lords, I shall be brief as we have been debating this for a long time. I spoke to this issue in Committee and, apart from the noble Lord, Lord Winston, and the noble and learned Lord, Lord Mackay of Clashfern, who is not in his seat, I was the only one to argue against preserving the HFEA’s current status and role, particularly on the clinical side.

I start by agreeing with the noble Lord, Lord Willis of Knaresborough, about the medical research authority. I totally agree with him that the Academy of Medical Sciences report has been widely accepted and backs the establishment of such an authority. It will also have an ethics committee because, according to the report, it will take over the national ethics service, which is currently run separately. It will therefore have an ethical body to assess the ethical issues related to all medical research. There cannot be any doubt about that. Last time, the noble and learned Lord, Lord Mackay of Clashfern, asked—and I have his permission to repeat the question—whether, in the interim, the Minister will find a way of establishing such an authority before the legislation is put in place.

I turn to the HFEA and its other role. Yes, it is true that we should all feel a glow when we mention the HFEA. When it was established, soon after the birth of Louise Brown, a voluntary licensing authority established by the Royal College of Obstetricians and Gynaecologists and the Medical Research Council had been operating for two years. Its creation gave both clinicians and the public the confidence that the newspaper headlines of the time—that monsters would be created in Petri dishes—would not be realised. It is true that in its formative years the HFEA did a fantastic and useful job in establishing and licensing premises for delivering good care to those requiring IVF treatment. Yet the world has moved on. More than 1 million children the world over have been born following IVF treatment.

There is no reason to think that the clinical care provided for patients requiring infertility treatment, including IVF, is any different, or should be any different, from the care provided for children with cardiac anomalies. Both treatments are properly regulated by the CQC and the professional organisations. We hear of units being shut down because of poor outcomes; so let us consider the recent performance of the HFEA. How should we measure it? We should measure it against the success rate for IVF. As the noble Lord, Lord Winston, mentioned, apart from spurious claims, there is no evidence that our outcome for patients requiring IVF treatment is any better than anywhere else in the world; in fact, it is poorer than in some other countries. Measured against promoting better outcomes for the patients, the HFEA has not delivered.

NHS: Standards of Care and Commissioning

Lord Winston Excerpts

Thursday 31st March 2011 Lords Chamber

[Lord Turnberg]

My Lords, I am delighted to have this opportunity of opening this debate. I am pleased that so many noble Lords are remaining in the Chamber and are going to contribute. I look forward to hearing what they have to say.

I shall focus my remarks on recent reports of failures in standards of care, particularly for the elderly, but this is also a good opportunity to examine whether the commissioning arrangements proposed in the new Bill will have a positive or a negative effect on standards of care. Perhaps, too, we should look at how the Bill might be used to make things better.

I am someone who has spent most of his life working in the NHS and I bow to no one in my support and admiration of what it achieves. I see enormous advances being made every year, and patients who would no doubt have died are now cured and surviving into old age. Medicine has been transformed out of all recognition during my working life.

It is because I have this pride and huge admiration of the NHS and the people who work in it that I now feel a deep sense of shame. Despite these wonderful advances, in too many places we have been ignoring the common decency needed to care for the vulnerable, the sick and the elderly—and it is the elderly who are often the most vulnerable. As Ann Abraham, the Health Service Ombudsman, said in her report, there is a,

“gulf between the principles and values of the NHS Constitution and the felt reality of being an older person in the care of the NHS in England”.

That is why I am going to focus on the elderly, but they are not the only group where standards have slipped. I suspect that other noble Lords may speak about the mentally ill, and only the other day we had a report about failures in maternity services.

Of course, the media are quick to pick up the seemingly occasional horror stories of neglect in a hospital. You might want to hide behind the idea that these are rare incidents against a background in which 1 million people are looked after perfectly well in our hospitals and nursing homes every 36 hours, and that is absolutely true. But it turns out that it is not a rare or unusual event. It seems to be happening far too often, and stories of neglect are just too common for comfort: patients, usually in a geriatric ward, unable to eat the food left out of reach at the end of the bed and collected by staff seemingly unaware that it has not been touched, and too busy to notice that a thirsty patient is unable to even drink without help—or, worse, too busy to notice that a helpless patient, unable to get out of bed and incontinent, is sitting in damp sheets for hours or, the final degradation, soiled by faeces and unwashed for days.

Noble Lords might ask whether I exaggerate. Where is the evidence that this picture is not just a rare, occasional lapse in an otherwise acceptable system of care? Well, quite apart from the rather common anecdotes of many with elderly relatives, there is now the report of the ombudsman in which she describes 10 examples of the complaints she receives that emphasise just how bad it can get.

We cannot say that we have not been warned. In 1997 we had the report from Age Concern in its “Dignity on the Ward” campaign, describing failing standards of care. When it followed that up 10 years later, in 2007, it found that little or nothing had changed. The Commission for Health Improvement in 2003, the Healthcare Commission in 2007 and the Care Quality Commission in 2010, despite regularly changing their names, came up with the same message. Now there is the book that has just been published, Michael Mandelstam’s How We Treat the Sick, which brings all this together in a devastating way.

The scandal at the Mid Staffordshire hospital of a year or so ago turns out not to be an isolated example. Every time we have a disastrous fall in standards we have another report or inquiry. I will not list all the hospitals or nursing homes that have been the subject of criticism but they range from Cornwall to Rotherham, from Tameside to Southampton and from Oxford to Bolton. There are just too many, and it is clearly not a new phenomenon. It went on under the past Government and the one before that, so I do not want to make any political points here. But how can we have tolerated this neglect of our most vulnerable citizens for so long? No one can afford to be sanguine—not the doctors, not the nurses, not the managers and not the Government. I want to say a few words about why and how this is happening and suggest what we might do about it, because we certainly cannot allow it to go on.

Let me apologise for starting with the nurses, for whom I have the greatest admiration and to whom I owe a great deal of personal gratitude. However, at the end of the day, it is the nurses who patients look to first for their personal care and empathy. It is always tempting to look back to a golden age that never was, but one thing that is clearly fixed in my mind is how high the standards of nursing care were on the medical wards where I worked in the 1950s and 1960s. Those were the days when the sister in charge of her ward really was in charge. She was usually a mature woman in a career job who made absolutely certain that everything ran efficiently and well. I admit to running scared of her; as, indeed, did the patients.

However, those were the days before the revolutions in nurse management and nursing education. One of the unintended consequences of the upward drive to better educated nurses with university degrees has been the development of a generation whose aspirations are set high. They quite reasonably expect to have a career in which they can practise their skills to a high standard. Who can blame them? They do a great job with all the caring attitudes you can wish for. However, that has left a gap at the more basic and, to many, less attractive level of the general and geriatric ward where there is greater emphasis on the basic needs of patients: feeding, washing, help with movement, going to the toilet and so on.

Those are the wards where staffing levels are often lower per patient in the belief that they do not need the more intensive, one-to-one care of the specialist units. So they are often understaffed and sometimes come to rely on temporary, or “bank”, staff, who constantly change. Continuity of care is damaged as patients, already a little disorientated by being removed from their familiar environment, are faced with a bewildering series of new faces.

It is not only the nurses who are constantly changing. Confusion is compounded by the way the rotas for the ward doctors are arranged to fit in with the European working time directive or as they rotate through yet another experience to chalk up on their training programme. So there are new faces at every turn. These wards do not have the champions that the specialised departments have, who can put pressure on management to protect them from cuts. Not much wonder that nurses in training pass through those experiences quickly on their way to higher things. Nursing sisters in charge may not stay long enough to be able to stamp their authority and, in any case, are distracted by paperwork or, nowadays, putting stuff into their computers—care plans and the like.

I fear that these changes have created a situation in which we have two starkly different standards of care. On the one hand we have highly trained, highly professional and caring nurses in well staffed specialised units—intensive care, coronary care, chemotherapy units and the like—and, on the other hand, poorly staffed wards, rushed nurses, falling morale, falling standards and poor supervision. These are the staff who are struggling to cope with patients whose vulnerability makes enormous demands for the care and attention that the nurses have neither the time nor the patience for.

Of course, this picture is not true everywhere and many, probably most, wards and hospitals are very good indeed. It is just that this picture is too common for us to take any comfort from it.

So what is to be done? Here it is clear that there is a need for a multifocused set of actions which no one profession or body can shirk. First, we must have someone at ward level who takes full responsibility for ensuring that patients are properly looked after with the respect and dignity that they deserve. That is absolutely key. I hope that my nursing friends will forgive me for saying that we should be making this job, the ward sister or charge nurse, a career post and rewarding those who do it accordingly.

[Lord Winston]

Hear, hear!

[Lord Turnberg]

My Lords, there has to be some continuity in that post to make it an attractive alternative to the lofty pastures of the specialised departments.

Then there is the issue of too few carers on the wards. What happened to all those state-enrolled nurses—SENs—whose roles were predominantly in the caring world and who did not aspire to higher degrees? They disappeared in project 2000. Is it possible for us to resurrect the SEN grade and make it attractive again? I hope that some thought can be given to that.

That leads me to the medical profession, who cannot absolve themselves—ourselves—from responsibility for the neglect we are now discussing. They, after all, must see the way their patients are being cared for and, I am afraid, have not raised their voices loud enough. They should be leading the charge for proper staffing levels on their wards. They should be pressing hard on the managers of their hospitals. Of course, they really must do something about these disruptive rotas that are destroying the continuity of care that patients need and deserve.

The managers must make themselves much more aware of their responsibility to ensure that there are sufficient staff on these wards to cope with what is one of the most demanding areas of a hospital. They should know that these wards cannot be among the first, for example, to take cuts. Then there are the responsibilities of the trust boards. Board members have to be rather more hands-on and need to know what is going on in their wards. Many obviously do, but it seems that there are too many who do not.

Finally, I come to those bodies who will be commissioning services in the bright new tomorrow, the GP consortia, and the responsibilities that we should be placing on them for standards of care in the NHS, under the Health and Social Care Bill coming through the House—in whatever form that Bill survives. To paraphrase Aneurin Bevan, there are bed pans clanging on the floor all over the country and, in the rush to devolution to the local level, important though that is, devolved responsibility must also mean some central accountability.

As these services are commissioned, we must make sure that the Bill places a duty on the GP consortia to make sure that high standards of care for the elderly, at least, are a contractual obligation on the providers. Furthermore, we must have a robust system of monitoring so that we can have some confidence that this care is actually being provided. Perhaps the proposed commissioning board can take this on, but only if it has the capacity to monitor what is going on in hospitals and nursing homes, and has a mechanism for action when standards slip.

We have been through too many years in which we have seen indifference punctuated by intermittent reports and wringing of hands. It has to stop. The time for action is now.

--- Later in debate ---

[Lord Winston]

My Lords, the points that I shall make are no criticism of the Government; indeed, they are not faults induced by them. If there have been faults, they have been those of healthcare professionals and the management of the health service. I hope that the noble Earl will be able to respond by saying how we can build in these suggestions. This is a strong echo of what the noble Lord, Lord Turnberg, said. He spoke with nobility, dignity and humanity and his points were very well made.

Some weeks ago, I brought to the attention of the House my experience at a leading hospital, where I was faced with a woman in her postnatal period, four days after delivery, with a dangerously high, life-threatening blood pressure, which no one was dealing with—she had not seen a doctor in four days. There was no continuity of care on the ward. When I tried to speak to the nurses, they were busy at their computers and with their paperwork.

I want to talk about the loss of continuity of patient care in the hospital service. The noble Lord, Lord Turnberg, talked about halcyon days. Although we may not want to return to those days, the old-fashioned firm system in medical practice was very good: the idea of consultants working in tandem, usually two at a time with the same secretarial support, followed by a senior registrar, a registrar, house physicians and house surgeons, was a good way to ensure continuity. Nowadays, we do not even have the privilege of interviewing the staff who come on to the team. Because of political correctness, they are often appointed. That means that we lose a valuable kernel within the health service.

There used to be flexibility about time off. We did not go off when a patient was really sick. We had a detailed handover when we went off, if we had to. We would make sure that the person to whom we were handing over understood what was going on. We were still responsible, as junior doctors, when we were off, and would expect to be informed if critical decisions were being made about those whom we regarded as our patients. That ethos and that culture have been lost, partly because of the European working time directive, although that is not the only reason. The restrictions on working time, which we have previously encouraged the Government to think about, have had a massive negative effect not only on training and experience but on morale and continuity. A “watch the clock” attitude has been engendered.

There used to be general ward rounds for the whole team, at which the ward sister would be an important person, together with the general practitioners. Often, general practitioners came to the wards, which meant continuity in society afterwards. Nowadays, we do not have the same attitude towards the hospital in which we work. We have no hospital nurse, no medical porters and no dedicated bedrooms. There is no staff dining room. That may seem a ridiculous point, but the disadvantage is that, in terms of morale, we cannot replace the staff dining room, where we used to discuss individual patients with other consultants in order to learn. In science units, restaurants and coffee facilities are in every research lab, but they are no longer in hospitals. We should think about that. I have to say that I learnt my haute cuisine of Indian cooking in such messes. We felt valued members of an institution in a way that we do not now.

As the noble Lord, Lord Turnberg, said, there is no leadership on the ward. Without ward sisters, individual nurses do not feel responsible for all the patients in their care on the ward. Doctors now normally do ward rounds without the sister present; indeed, it is difficult to find a nurse who is free.

I make one final point. Basic nursing has been lost: cleaning patients, caring for them, listening to them, trying to feed them occasionally. Yesterday, I met a paediatric nurse at one of the best nursing schools in the country. She said: “I got an A in hospital management and NHS management in my essays, but I cannot change a paediatric colostomy bag, and that really worries me”.

Public Bodies Bill [HL]

Lord Winston Excerpts

Wednesday 9th March 2011 Lords Chamber

[Lord Mackay of Clashfern]

My Lords, I declare an interest as an honorary fellow of the Royal College of Obstetricians and Gynaecologists and as the person who had the privilege of introducing to this House the Bill that ultimately became the Act which has been referred to more than once. As a parent of such a body, it would be strange if I wanted to see it dissolved altogether. On the other hand, a parent who is interested in his child is glad to see him or her develop and possibly make unions with others who seem to be suitable for them. I had the honour of serving on the Joint Committee looking at the recent Bill in this area under the distinguished chairmanship of the noble Lord, Lord Willis of Knaresborough. I strongly supported the decision taken by that committee to recommend against the proposed union between the Human Fertilisation and Embryology Authority and the Human Tissue Authority. I think I am right in saying that the noble Lord, Lord Willis, may have done a slight injustice to the noble Lord, Lord Warner, because I think the noble Lord, Lord Warner, said that he had recommended against it to the Minister. I do not know whether the Minister accepted it immediately, but eventually it was accepted by the corresponding Minister.

The matters that were the subject of the Bill which I had the privilege of introducing are certainly among the most important areas of modern scientific and medical work. But science and medicine have moved on very fast and far since that Bill was introduced and the developments dealt with in the most recent Act show that. That Act moves out of pure human embryology to the transition towards hybrids and, at the extreme end, towards the animal end of embryology. It shows that science has developed in such a way that the distinct field carved out in the original Bill has been altered by progress, if you like to think of it in that way, and I hope that that is what it is. There is a great deal to be said for the view that modern scientific and medical research is very difficult to split up. The embryo is important, but there are other important aspects of that research. I can therefore see a very strong argument for having a research body which has overall responsibility in this area.

There are of course other functions in HFEA which are important, particularly the control of IVF. When the body was originally set up, the practice of IVF was exceptional and a complete novelty, but a lot of water has gone under the bridge since then and it has become much more of a standard clinical procedure. It is true that developments have taken place there, but they have taken place also in other branches of medicine. It is not only embryology or IVF that have moved forward; fortunately, a great number of developments have taken place in the practice and application of medicine and surgery. It strikes me as extremely logical to have a body that would have overall responsibility for that.

If that be right, there is a good deal to be said for the view that the time has come to review the position in regard to the two health bodies that we are discussing and see whether a more integrated approach to research on the one hand and clinical practice on the other could be furthered by having bodies responsible for the whole of the first and the whole of the second. I agree that a good deal of detail needs to be filled in, but I remind myself that we are not deciding today whether this should happen. We are talking about a power for a Minister to decide what to do in the light of the further consultation provided for in the amendments moved by the Government since the Bill has been in Committee. It is a valuable opportunity for these matters to be considered. I can understand a lot of what has been said on the other side of this argument, but I should like to see retained in the Bill the power to deal with these issues in a way that reflects the developments that have taken place in the research and practice of medicine since the original Act came into force.

[Lord Winston]

My Lords, my noble friend Lord Warner has declared support for the Minister sitting on the Front Bench; I suspect that I might in the next few minutes give him even greater support.

We have to understand that research in these areas has now gone way beyond embryology. There was a time when people were very concerned about the status of the embryo, when embryo research was relatively novel. I should like to correct a remark made by the noble Lord, Lord Walton, who very kindly referred to work on pre-implantation diagnosis. That work produced pregnancies before the establishment of the Human Fertilisation and Embryology Authority, and people like me were greatly exercised to establish regulation. In spite of what has been said in this Chamber, we were very much in favour of regulation. Since there was no government regulation, we started a voluntary licensing authority which became a model in time—obviously, a very imperfect model—for the body set up under the splendid Bill introduced by the noble and learned Lord, Lord Mackay of Clashfern.

Stem cell biology covers every aspect of human disease, from cancer to brain research, from human consciousness to the replacement of organs and transplantation, and a whole range of other areas. It is really—forgive the pun—inconceivable that this could be dealt with by the Human Fertilisation and Embryology Authority properly under its present form or any future form. I would argue that with the advent of epigenetics, the recognition that now the environment in which cells are placed in culture and elsewhere is such a universal issue in medicine there has to be a much more global look at this kind of research. I feel that there is a strong case for suggesting that we have to accept that research ethics are universal and that they tend to have the same sorts of problems, whether it is patient consent, the end or beginning of life, or a whole range of other issues. In fact, the end and beginning of life have some very similar moral issues which need to be debated by ethics committees. The noble and learned Lord was right to point out that trying to look at these issues in a new form would be absolutely apposite. I for one am certainly not in favour of a free-for-all. I am not quite certain who in the medical profession is. I do not think that that is true.

The regulation of clinical treatment has been in many examples woefully inadequate. The noble and learned Baroness, Lady Butler-Sloss, pointed out that while she was sitting on the Bench she had the most terrible case of a woman who had the wrong embryo transferred. That was done, of course, under the auspices of the Human Fertilisation and Embryology Authority. No regulatory authority, no matter how perfect or how good, can regulate against every human error. We should have a set of principles in laboratories which keep those mistakes to a minimum, and the regulation of medical practice must also enforce that.

I do not think that there is any evidence from what has happened that the HFEA has done a particularly good job or a particularly bad job. In some areas it has not been very powerful. For example, many things are forbidden under regulation in this country. Patients actively seek fertility tourism in other countries where they can get, for example, donor eggs and perhaps come back pregnant. Very often clinics in this country, although it may be against regulations, refer these patients outside. Of course the HFEA, not unreasonably, is powerless to deal with that sort of problem.

It is also true that the fees charged to patients are often extremely exploitative. I have no doubt that we will come back to this when we come to the pending health Bill, because this is a much bigger issue in terms of how we finance the health service. At the moment, IVF, whether it is done in the private sector or in my view in the National Health Service, is charged on the basis not of what it costs but rather of what the market will bear. That is a very big issue which we will need to discuss, because I suspect that that may apply to a lot of medical practice. It is an issue to which I am sure this House will want to return. Costing the procedure is very important.

Someone mentioned follow-up: one sad thing about the opportunity in 1990 was that we did not—even though we had records of IVF pregnancies, and IVF successes and failures—make any attempt to follow up babies after this procedure for the long term. There have been many reasons why that was difficult, such as data protection. But this lost opportunity means that some of the procedures often in routine use may have unforeseen consequences in children when they are adults. We now know from David Barker’s work, for example, that babies who are born underweight and premature are much more likely at the age of 50 or 60, as the Minister knows, to suffer from heart disease, stroke, hypertension and possibly osteoporosis as well as diabetes and one or two other diseases as well. Of course, we may see more diseases which are likely to be epigenetic due to those early influences.

I have to say that, although it is claimed that the HFEA gives out information to patients, six years after I retired from clinical practice running a very large IVF service, I am bombarded daily with e-mails—I have had several today—from patients who want information about IVF and do not feel that they are getting the information they should from the statutory authority. That remains a problem.

The clinical regulation of non-evidence-based practices has been poor. For example, there is no evidence that the preimplantation and genetic screening of embryos designed “to improve pregnancy rate” works. Yet several clinics charge large fees for doing this under regulation even though there is not a base for justifying its use. That also applies to costly immune therapy, which is highly controversial. Again, this is used in women who sometimes fail to get pregnant, under licence from the HFEA. This is an example of how in fact regulation is really quite limited in clinical practice.

--- Later in debate ---

[Baroness Deech]

My Lords, on a factual point, may I correct the impression—it may have been a mistake— that the previous speakers have given that any number of embryos can be implanted in a patient? The HFEA brought down the number of embryos from three to two and is working towards one. That was in the face of relentless resistance from patients, who wanted the best chance of becoming pregnant, and indeed many—but not all—of the clinicians and embryologists, who said, “We know what’s best for our patients”. The impression should not be given that an unlimited number of embryos are implanted. The number is two and they are working towards one.

[Lord Winston]

Forgive me for correcting that impression. Many units limited the number of embryos well before the HFEA did. At Hammersmith Hospital, we limited the number of embryos two years before the HFEA did. We were not alone; a number of units did that because we were very concerned. The idea that medical practitioners do not feel responsible for the pregnancy that is induced is, I think, a dangerous precedent. It is just not true. Of course there is a problem when patients put you under pressure, and it is a very difficult ethical issue that needs to be resolved.

[Lord Patel]

My Lords, I think I have lost my thread, but I have said what I wanted to say.