Access to Palliative Care Bill [HL]

Viscount Bridgeman Excerpts

Friday 23rd October 2015 Lords Chamber

[Viscount Bridgeman (Con)]

My Lords, I am the last of many speakers today to congratulate the noble Baroness, Lady Finlay of Llandaff, on this, her latest contribution in her distinguished record of palliative care treatment in this country. I declare a non-pecuniary interest in having been for 11 years chairman of the hospital of St John and St Elizabeth in St John’s Wood, London, which, unusually for the hospice movement in this country, has within it St John’s Hospice, forming part of the same charity. In common with most other hospices of similar size—in this case, 22 beds—St John’s has contracts with a number of adjacent health authorities, in its case seven in north and west London. I have to say that patients who are near the end of their lives, whether they wish to spend their last days at home, in hospital or in a hospice, are liable to find themselves participants in a postcode lottery —rather surprisingly, in such a small area of London.

I shall give your Lordships some examples. Hospice at home is developed by many hospices. It is vital but it has administrative problems. Statistics show a slow but steady increase in end-of-life patients wishing to spend their final days at home. Some of the health authorities in the group pay for hospice at home but some do not. Some commissioning groups, which are the flagship of the innovations in the 2012 Act, pay great attention to palliative care but, regrettably, others—again, this is the experience of the hospice with which I am familiar—have palliative care low down on their list of priorities, a point that has been raised many times in this debate. Again, I refer back to hospice at home: here there are, more than ever, likely to be continuing problems of communication as most are elderly patients, many with varying degrees of dementia and of course in dispersed locations. In the catchment area of St John’s, several CCGs do not include in their team the post of palliative lead GP, a GP who, being especially experienced in palliative care, is ideally placed and qualified to ensure good communication with patients at home, and indeed good communication between hospice and CCG. Here again, some CCGs have this very important post and some do not.

A final example of the postcode lottery is the matter of contracts between hospice and health authority. In the St John’s group, only two out of seven health authorities have contracts for more than one year —in both cases, for three years. This is probably outside the scope of the Bill but the advantage to both parties is obvious with regard to long-term planning, and it is surely likely to be reflected in the treatment and facilities available to end-of-life patients with the right postcode.

How, therefore, is all this addressed in the Bill before your Lordships? I suggest that that very point I have sought to raise is addressed directly or indirectly in the Bill under Clause 2(2). In its 10 paragraphs there is in effect a series of minimum benchmarks of performance which I am confident should serve to raise minimum standards across the board and thereby go some way to eliminating the more glaring effects of the postcode lottery to which I have referred.

In conclusion, I must say a word about funding of the hospice movement, which has been referred to, particularly by my noble friend Lord Howard of Lympne. Traditionally the funding of hospices by Governments of all parties has varied widely, from 50% of operating expenses down to percentages in the 20s. The noble Lord, Lord Howarth of Newport, has of course referred to children’s hospitals, where funding is even lower than that. Therefore the shortfall has to be found from appeals and other fundraising events, and £1 million a year is probably the bottom-line requirement. I suggest that there is degree of cynicism on the part of government in all this. This is not a party-political point—it is common to all Governments. Every Government know that in the end virtually every hospice always gets its operating costs funded from somewhere.

I therefore say to the Minister: what a marvellous opportunity for the Government to show their appreciation for this marvellous movement, which, as the noble Baroness, Lady Finlay, has reminded us, leads the world, by at least raising across the board the average percentage of support which they are able to give.

National Health Service: Sustainability

Viscount Bridgeman Excerpts

Thursday 9th July 2015 Lords Chamber

[Viscount Bridgeman (Con)]

My Lords, I, too, associate with other noble Lords in thanking the noble Lord, Lord Patel, for this very timely debate.

I have, on many occasions, talked to visitors from overseas who have used the NHS and who have told me how impressed and indeed amazed they were by the fact that the treatment had not cost them a penny. Free at the point of delivery is the bedrock principle of the NHS and admired throughout the world, and I will have more to say about that. This sits alongside the unpalatable fact that it is generally agreed that, by 2020, there will be a £30 billion deficit, in addition to all the deficits running at that time.

I strongly favour a royal commission. Arguably, its most important effect would be to take the NHS out of politics to enable the whistle to be blown, as my noble friend Lord Mawhinney has said—though whether it can remain in that condition is a future challenge for abilities greater than mine. I suggest that its brief should address, among other things, the question of free at the point of delivery. This is not only an admirable ideal in itself but, over the past three or four generations, has come to be regarded as a fundamental birthright. In political terms, frankly, no party would dare to question it. However, with a royal commission, politically unfettered and drawing on many government departments other than health, there appears to me to be a once in a lifetime opportunity to address this issue. I suggest to your Lordships that such a commission would have the unbiased authority that would enable it to address the unthinkable of some form of selective contribution by patients for treatment—the noble Lord, Lord Crisp, has obliquely referred to this—moving towards the ultimate goal of a financially viable National Health Service.

The other point that I hope the royal commission would address has fortunately been answered already by the noble Lord, Lord Kakkar, who made the point of the need to address the national healthcare services in other OECD countries, and the noble Lord, Lord Crisp, has given some examples.

In 2002-03, general practices were offered a new contract—personal medical services—which offered better funding if they undertook more services. Those that took up the new contract tended to be the more entrepreneurial practices. In central London, to take one example, take-up was around 50%. The national policy has been to reduce PMS funding to that of GMS, the pre-existing contracts. I quote a doctor friend, who is one of the people concerned:

“They say that they will return any saving from PMS reviews to the local health area. There is no guarantee that that would substantially make up for lost funding. In one area I know of practices that stand to lose over £400,000 pa, which will cripple them”.

His own practice stands to lose over £300,000—we are talking about west London. He continues:

“At a time when primary care is being promoted as a means of achieving substantial savings, by enhanced and new ways of working, it seems counterproductive to make swingeing cuts in often the most innovative and high quality practices”.

I suggest to your Lordships that this is a very short-sighted measure.

NHS: Medical Competence and Skill

Viscount Bridgeman Excerpts

Wednesday 7th January 2015 Lords Chamber

[Viscount Bridgeman (Con)]

My Lords, I thank the noble Lord, Lord Parekh, for securing this debate. I will venture to speak on a subject which has some relevance to its title and to the noble Lord’s speech—that is, the problem of English language testing for health professionals from the EEA working in the United Kingdom. I speak with particular reference to nurses, with whom I have some familiarity, but my remarks should apply also to dentists and pharmacists. I know that other branches of healthcare are in the pipeline for similar consideration.

I am sure your Lordships’ experience of nurses in the NHS from the EEA is overwhelmingly one of courtesy, competence and compassion. Nevertheless, I am sure they will also have had instances of language difficulties over health workers’ command of English. The background to this problem is the mutual recognition of professional qualifications directive of 2005, which covers the mutual recognition of professional qualifications within the EEA. As originally promulgated, this contained the requirement that registration in the respective countries should be done before any testing for English language capability, the argument being that imposing language tests before regulation inhibited one of the EU’s basic concepts, the free movement of professionals within the Community.

This gives no problems with professions such as surveyors, architects or engineers. However, healthcare is in a category of its own because there is the additional consideration of patient safety, and this has caused considerable problems for the regulating bodies. For instance, the Nursing and Midwifery Council has been obliged first to register candidates without being able to assess their English language proficiency. Control over its members tends to be lost, or at best diminished. A fully registered nurse, probably in employment, is not going to take lightly to being told to go back to school to improve his or her English. Indeed, the onus for language competency currently rests with employers, a far from satisfactory position. This has been the potential scenario for disasters waiting to happen. We are fortunate that there have been no serious ones. However, as a journalist has pointed out, the difference between a milligram and a microgram can be a coffin.

Over the past few years the Department of Health and its associates in the three devolved Administrations have been involved with the Commission in addressing this problem. Fortunately, a lead was given by the GMC, which last year achieved a very satisfactory outcome in respect of doctors. If we turn to the other branches of healthcare, in November 2014 the department and its counterparts in the devolved Administrations issued a four-country-wide paper for consultation, the outcome of which has been a draft Order in Council which, I understand, will be due for debate in both Houses in the course of this Parliament. The effect of this should be that the regulating bodies will have the powers to delay registration of a candidate from the EEA if they are not satisfied with his or her language competence. This development should rectify a serious defect in the freedom of movement legislation, and I congratulate my honourable friend Dr Dan Poulter and his colleagues in his department and the other devolved Administrations on their diligence in achieving this potentially favourable outcome.

This may appear to outsiders to be a minor procedural adjustment. I suggest, however, that it is in fact of great significance. Not only should it be a step towards reducing accidents caused by poor language communication but, of no less importance, it will enhance the standing and credibility of the respective regulators—the Nursing and Midwifery Council, the General Dental Council, the General Pharmaceutical Council and the Pharmaceutical Society of Northern Ireland—in giving them greater control over their members in ensuring that those from the EEA go into the employment market with the necessary competence in English.

NHS: Better Care Fund

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Thursday 3rd July 2014 Lords Chamber

[Viscount Bridgeman (Con)]

My Lords, I thank the noble Lord, Lord Kennedy of Southwark, for initiating this very important debate. He has rightly emphasised the need for early treatment of so many of the complaints which he outlined. It has long been recognised that there is a great need for integration of health and social care because this can support people better by improving their health and well-being by ensuring continuity of care while making better use of resources.

The basic mission of the better care fund is for health and care support to work together. From it flows, for instance, acting earlier and improving health education so that people can stay healthy and independent at home, thus easing the strain on hospitals and A&E, and from it also flows care which is tailored to individual needs with NHS and social care staff working together to provide seven-day services with a named co-ordinator.

The better care fund of course faces two challenges coming from very different directions. The first is the funding crisis common to the health sector and local authorities and the second is the increase in life expectancy mentioned by the noble Lord. Nevertheless it is a bold initiative. I welcome the tight but, I hope, not bureaucratic control over the operation of the scheme. One billion pounds of the fund will be tied to local performance. Peer support will be available to those areas which do not perform well. I also welcome the flexibility of the scheme by which £3.8 billion will be pooled in local areas, but the two services will be permitted to go further with additional funding where local conditions make this appropriate. There is a clear mandate for control of the funding to rest with NHS England which in turn will require clinical commissioning groups to use powers under Section 75 of the National Health Service Act 2006 to set up pooled budgets with local authorities. I welcome the checks and balances, for instance, that money from a pooled budget can be spent only with the agreement of both parties, with such spending agreed with the health and well-being board. In cases, which I hope will be rare, where the scheme is manifestly not working, it will be the duty of NHS England to intervene and instruct the CCG to come up with a solution.

Not for the first time, the King’s Fund has come up with a well researched document which draws together a number of studies relevant to the better care fund. It has produced a number of very practical suggestions for making this body viable and effective in its early years. The King’s Fund’s work contains its customary bibliography, and I am sure that the Minister, his department and, indeed, NHS England have taken note of the many constructive suggestions which it contains. The study fully acknowledges that this is a difficult time for the NHS in terms of funding. For instance, of the total of £3.8 billion budgeted for the fund, £1.9 billion will come from allocations to CCGs. It will not be new money. Guidance has come from NHS England that hospital emergency activity will have to reduce by 15%. We are in all-too-familiar territory here. Where patients go, whether to their GP or to A&E, justifies a debate on its own. Suffice it to say here that if the 15% reduction in emergency activity is to be reduced to assist the funding of the BCF, for the hospital it is a matter of considerable urgency.

Many of the recommendations contained in the King’s Fund document are contained in the admirable house of care programme developed by NHS England, which outlines so much of what the BCF should aim to achieve. I shall list only some of them: greater forward planning for LTC patients; involving patients in the self-management of their health; greater access by patients to their health records; agreed common goals for the NHS and care services; and emphasis on staff training. All these are common-sense aspirations—there is no rocket science here—but it is useful to have these brought together in a user-friendly document.

I return to the subject of the 15% reduction in hospital admissions. The Nuffield Trust, in particular, has made a study of more than 30 integrated care programmes, many of which had reducing urgent hospital admissions as a key goal. There have been a number of press reports suggesting that there is a real danger of financial collapse in the hospitals sector. I hope the Minister will confirm that across England there have been a number of pilot operations of the BCF model. I should welcome an update from the Minister on the results of these pilots and his reassurance that this very real problem relating to hospitals is being addressed.

Finally, I think it is true to say that attention has rightly been concentrated on getting the BCF off the ground in 2015-16 and in its first year of operation. Here I take up the point made by the noble Lord. I note that the Local Government Association chairman, Sir Merrick Cockell, while giving his strong support to the BCF is concerned about the longer-term funding, saying:

“Health and social care partners have shown their confidence in joining up their funding by putting in additional money over and above what was required by the Department of Health, but despite this there has still not been any indication that funding will be extended beyond this first year”.

I, too, hope the Minister will be able to say something about the Government’s plans for longer-term funding of the better care fund, the concept of which is welcomed from all quarters.

Medical Act 1983 (Amendment) (Knowledge of English) Order 2014

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Tuesday 11th March 2014 Grand Committee

[Lord Kakkar (CB)]

My Lords, I declare my interest as a member of the General Medical Council and I would like to take this opportunity to congratulate the noble Earl and Her Majesty’s Government on dealing with this important issue in what I think we can all agree is a very sensitive way. There is no question but that our health services are vitally dependent on a steady flow of doctors coming from all parts of the world, including the European Union. Not only can they learn from our healthcare system, they can also serve in it. But it is absolutely right that a professional regulator must enjoy the confidence of the public, and it is the responsibility of the General Medical Council first and foremost to ensure that patients are protected and that clinical practice in our country is safe.

For that confidence to exist, the public have to be sure in their own minds that the elements of what they would consider to be essential clinical practice—the ability to practise in a responsible and safe way—are met and tested by the General Medical Council whenever it feels the necessity to do so. The ability to communicate effectively, and therefore to use our language in a way that the public and patients appreciate and would expect, is an essential part of the responsibility of the regulator of the medical profession. As we have heard during this short debate, it is anomalous that the GMC is able to ask that question of potential registrants and licensees from outside the European Economic Area, but has not been able to do so of those who come from within the European Union. It is quite right that the Government have focused on this issue and decided to act in this fashion.

The fact that this order makes provision not only for the question at the time of licensing of a professional, when concerns about language skills might have been raised during the provisional registration process, but also that the new category of considering the ability to use language and to communicate becomes part of the broader question in fitness-to-practise considerations, is vitally important. It means that not only at the time of coming on to the register and being licensed to practise in this country, but throughout the practice itself, the public and patients can now feel confident that the General Medical Council will be in a position to act if it needs to do so. The importance of that cannot be overestimated.

We have heard about the additional question of competence skills, which is a matter that your Lordships have considered in the course of a number of debates in the Chamber over the past few years. The issue remains to be addressed, but I think that most would agree that ultimately, wherever a doctor comes from in the world, whether they have trained and qualified in our own country, elsewhere in the European Union or elsewhere in the world, they should be expected to demonstrate their skills to the same standard and to deploy those skills throughout their professional career in a way that enjoys the confidence of the people of our country.

[Viscount Bridgeman (Con)]

My Lords, I rise with some diffidence as the first layman to address your Lordships in this debate. I, too, thank the Minister for his statement and pay tribute to his department for the leadership that it has shown in securing from the Commission the remedying of what was a glaring and potentially dangerous anomaly in the 2005 directive. The Commission has produced a very satisfactory outcome.

I believe the United Kingdom is among the first member states, if not the first, to incorporate the changes introduced by the revised directive into legislation. I note that the order is headed:

“Health Care and Associated Professions”.

I hope the new language-testing arrangements will be incorporated as early as possible into other branches of healthcare—I have nursing in mind in particular. I think it is the experience of many that nurses from the EEA are almost invariably pleasant, caring and considerate. They of course play a huge role in this country, but I know that many patients have had difficulty in communicating and in making themselves understood.

There are many reasons why this is a matter of some urgency, but I will suggest just one. I think I am right in saying that the practice of putting great emphasis on patients’ notes goes back a long way in the UK; possibly more emphasis than some other member states, even those with advanced healthcare arrangements. It is therefore all the more important that nurses from the EEA are proficient not only in spoken but in written English, a point which the noble Baroness, Lady Finlay, made in connection with doctors. As one facetious journalist put it,

“the difference between a microgram and a milligram is a coffin”.

I hope the Minister can give your Lordships the assurance that progress is being made in extending the provisions of the revised directive right across the healthcare profession, not least with nurses. I hope that this will include the fitness-to-practise hurdle, which is so important in reinforcing the ongoing responsibility of the relevant regulators for their members.

[Baroness Brinton (LD)]

My Lords, I am also a layman so the noble Viscount, Lord Bridgeman, need not feel completely alone. However, I preface my remarks by saying that my grandfather was the dean of St Mary’s Hospital Medical School. I remember him trying to explain to me why a bedside manner was not just about translating medical language but was all about speaking and listening. The one point I would add to the many that have been made by noble Lords this afternoon is the one about communication. A technical knowledge of English on its own is not enough—it needs to be one that picks up not just the body language but the nuance, including of regional language. If a Yorkshireman says he is “probably alright”, you know that you would want to question him further, whereas somebody coming from overseas might take that at face value.

I leave the rest of the medical comments to the medical professionals, who have spoken amply in that respect, and want to speak very briefly on freedom of movement in the EU. My party certainly believes that it is vital but—in true liberal tradition—it is fine up to the point at which it harms other people. It has been quite clear, certainly with one very celebrated case but also with others that may not have hit the public eye, that the capacity to cause harm is now at a level where action needs to be taken. These changes are well overdue and I am very pleased that they will set a new framework for the General Medical Council and restore confidence in foreign doctors from the EEA, wherever they are from and whatever level of language they have.

I end on the point that proportionate language competence must not only be checked but be checked more frequently than the BMA perhaps would like, because language and communication skills can get rusty.

NHS: Seven-day Working

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Thursday 6th February 2014 Lords Chamber

[Viscount Bridgeman (Con)]

My Lords, the whole House will be grateful to my noble friend Lord Ribeiro for securing this debate. He produced devastating statistics from Sir Bruce Keogh and NHS London but this debate surely cannot be complete without revisiting the working time directive. I have one or two further telling facts from my noble friend’s own royal college. For example, 86% of surgical trainees working to a working time directive-compliant rota have seen their work-life balance deteriorate. A survey published by Pulse of 500 junior doctors on the impact of the working time directive reported that 65% of respondents felt that it is having a detrimental effect on their training and 75% felt that there is now insufficient cover on the wards.

Further analysis by the royal college says that the number of hours available to surgical trainees for training and experience in compliance with the working time directive has been significantly reduced. Every month, 280,000 surgical training hours are lost to that directive and the doctors beginning their surgical training today will have 3,000 fewer hours to learn throughout their training, which is the equivalent of 128 whole days. This is but a snapshot of the telling statistics showing the handicap which the working time directive is imposing not only on patients today but on the precious investment in young medical talent for the future.

My message to my noble friend the Minister is to ask what pressure can be brought on the Commission to improve the working of the directive, which, let us not forget, has at its core wholly admirable aims. The Commission does listen. The United Kingdom, led by the Department of Health, has over the past two years taken the lead in inducing the Commission to modify the free movement directive which has hitherto prohibited the regulatory bodies in healthcare, such as the GMC and the Nursing and Midwifery Council, from testing health workers from the EEA for English-language competence before registration, potentially releasing healthcare workers on to the market with less than adequate English. That is a disaster for patient safety waiting to happen. The Commission has now listened and taken measures to modify the directive to ensure that language competency is established before a certificate of fitness to practise can be issued.

I use that as an example where the issue was patient safety. Let us be in no doubt that in the case we are debating it is simply that again, whether it is in the inadequate training of doctors to which I referred or the lack of continuity which was provided under the old structure of the firm, whose demise was one of the principal casualties of the directive. The introduction of the shift system also plays against continuity. Can my noble friend give an assurance that his department will build on his earlier successes with the Commission and give a high priority to securing a modification to the working time directive?

I finish with an instance which I assure your Lordships is not simply hearsay. I know of doctors who need to get work experience in another country within the European Union. Both the time and money available are limited and, to get the best value out of their secondments, they have quite simply chosen to go to member states where the working time directive is openly disregarded. By the way, these are not newer accession states but old, western members of the Union with highly sophisticated health services. This country has a history of abiding by the law and I leave my noble friend the Minister, and all your Lordships, to draw their own conclusions.

NHS: EU Legislation

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Monday 21st October 2013 Lords Chamber

[Earl Howe]

My Lords, the noble Lord will know that doctors from the European Economic Area are deemed to have professional skills equivalent to those of doctors trained in this country. When doctors come from outside the European Economic Area, then, indeed, the GMC puts procedures in place to ensure that the skills of those professional people match those that we would wish to see in the National Health Service.

[Viscount Bridgeman (Con)]

Can the Minister confirm that the proposed amendment to the free movement directive now gives competent authorities the powers to test EEA nurses for English proficiency before they get clearance to practise in the UK? If that is so, is it, in the Minister’s view, adequate in the interests of patient safety?

[Earl Howe]

My Lords, my department is absolutely committed to ensuring that regulated healthcare professionals are not able to work in the NHS without adequate English skills. The revision of the mutual recognition of professional qualifications directive, which impacts on registrations from within the EEA, clarifies that regulators such as the NMC can undertake proportionate language controls on professionals following registration.

EUC Report: Healthcare Professionals

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Thursday 22nd March 2012 Lords Chamber

[Viscount Bridgeman]

My Lords, I thank the noble Baroness, Lady Young of Hornsey, for initiating this debate and I congratulate her on the excellence of the report. I am in a position to say that as I only joined the committee after it had been published. The noble Baroness has set out the timetable for the various consultation papers which have appeared, possibly inconveniently, at the same time as the report. It has to be said that the Commission’s draft on the amendments to the 2006 directive, on which many had pinned high hopes, at first glance is disappointing on the matter of language testing. However I am assured by a number of competent authorities—regulators—I have spoken to that, in reality, slow but sure progress is being made. Again, the noble Baroness has confirmed this.

Let me take one or two specific points relating to language testing. Proportionality, a basic concept of the European Union, has been replaced in the amending document with “when strictly necessary”. I am assured that either of these expressions, each of them as long as a piece of string, is fundamental to the EU principles and that this concept has been upheld in several cases before the European Court. I simply ask the Minister whether, in his negotiations with the Commission together with BIS, the Commission has fully taken on board that healthcare is the most prominent among a small group of professions where patient safety is a vital consideration, in addition to but quite discrete from other factors such as a mutual recognition of qualifications that goes right across the group. In talking to some of the UK bodies, I wonder if the Commission has fully taken this on board. I remain suspicious that patient safety remains as it has been to date; that is, sidelined in favour of single market dogma. Is there not a fundamental complacency about this?

I note that at paragraph 73 of the report, Emma McClarkin MEP is reported as saying in evidence that there have only been “occasional problems” with competent authorities over the issue of language testing. One death that is attributable to language misunderstanding is one death too many. As I have read somewhere, the difference between a milligram and a microgram in dosage can be a coffin—a smart bit of journalism, but surely that says it all. So there is almost universal agreement that the draft amending regulations as they apply to language testing are not sufficiently specific. I hope that both departments will take on board the message from this debate that they should aim towards unequivocal drafting which ensures that, in this matter, patient safety transcends any other consideration.

The committee’s report makes the point with elegant moderation:

“We consider that the Directive currently strikes the wrong balance between facilitating mobility and ensuring patient safety, which must be the overriding concern. Furthermore the current system undermines public and professional confidence in the mobility of healthcare professionals within the EU”.

I would take this point further. The regulations as they stand inhibit the status of the regulators within their own respective disciplines. After all, what is the raison d’être of a regulating body if it cannot adequately monitor its membership?

Perhaps I may make my own position quite clear. In my view, our aim must be that Article 53 is amended so that healthcare authorities in each member state have the power to impose whatever language testing they think fit. In some cases this may amount to blanket language testing, something the Commission has set its heart against. In other cases, the regulators may consider that some lower level of testing is adequate.

The sub-committee’s report covers the matter of language testing with clarity and common sense, and its proposals are admirably set out in paragraphs 82 to 85. These include provisions for monitoring the language skills of self-employed professionals, an area which in the Commission’s own admission is inadequately covered. There is also the very practical suggestion that, in view of the length of time required to effect legislative change, a code of conduct is an effective and relatively speedy route for clarifying with competent authorities what the directive currently permits with regard to language testing. Finally, the committee is not in favour of restricting language testing to those professionals who come into contact with patients.

In talks with various regulators, I am reassured that slow but steady progress is being made by the Department of Health and BIS in their negotiations with the Commission. I feel that we are all talking to the same purpose and this is very welcome. But perhaps I may ask the Minister whether he will continue to make the point that, whereas proportionality is a fundamental principle going back to the treaty of Rome, the matter of patient safety is quite frankly even more fundamental than that, and that it is patient safety which must in the end prevail.

Nursing

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Thursday 1st December 2011 Lords Chamber

[Viscount Bridgeman]

My Lords, I thank the noble Baroness, Lady Emerton, for her expert and sensitive treatment of this subject. I am afraid what follows now will be a slightly inadequate summary of what she began by saying and reverted to later in her speech—that is, the fundamental challenge to the training of nurses in the United Kingdom. As she reminded us, the trend over the past 10 years towards the requirement that nurses should be educated to degree standard is a desirable objective in itself. It makes nurses better equipped to address the ever increasing sophistication, both in treatment techniques and in equipment, and crucially it gives student nurses who are so motivated the chance to aspire to management positions within healthcare.

The downside of this, to which the noble Baroness has referred, is that during this period of nurse training a decreasing amount of time is spent on the ward with hands-on experience of dealing with patients. This is compounded by the fact that there is not the same opportunity for the junior nurse to learn from the ward sister—who I suppose one must now refer to as the ward manager—who can pass on his or her experience. These individuals so often find that the nursing teaching posts are more attractive than hands-on nursing and it is to these that many of them move. This is a problem which is not going to go away; frankly I see no immediate solution and I should welcome comforting words from the Minister.

I have some recent experience of the healthcare sector as a former chairman of an independent hospital in London, the Hospital of St John and St Elizabeth. On the whole, the independent hospitals have been able to retain the traditional system of the matron having total responsibility for the nursing staff, with the ward sister or manager looking after patients on the ward and, crucially, having responsibility for services such as cleaning. It would be both arrogant and unrealistic, coming from the independent angle, to say “If we can do it so can you”. There are so many differences between the environments of the National Health Service and the independent sector that it makes such a glib suggestion inappropriate, not least the organisational demands which a body the size of the National Health Service faces. Furthermore, on a personal note, I wish to place on record the great help and support the hospital with which I was associated receives from the NHS in many, many ways. There should be no misunderstanding about this—I am not referring to financial help. However, it is important that the two sectors have regard for each other, possibly to their mutual benefit.

Let me recount one experience I had which I think may be relevant to this debate. While the independent sector struggles to attract good nursing staff as much as the NHS, most are fortunate in having a satisfactory body of trained nursing staff. However, many of these hospitals, including my own, also operate a programme of giving work experience to trainee nurses in the NHS. Ours formerly involved an arrangement with one newish university in the London area. On more than one occasion, Matron was somewhat startled to come across the attitude “I am not interested in the nursing, I am only here to get something on my CV”. Subsequently—and understandably— the change was made to sourcing from one of the London teaching hospitals where we encountered a totally different type of student nurse—keen and committed, potentially a credit to the nursing profession.

The wastage of resources in the nursing training programmes of some institutions is self-evident and I would welcome an assurance from the Minister that his colleagues in the DoH are monitoring this, and particularly the suitability of candidates for these training schemes. My message to your Lordships—and, indeed, the Minister—is that I see no easy, quick-fix solution to the present less-than-perfect juxtaposition between academia and ward experience.

In conclusion, perhaps I may return briefly to the subject of ward cleaning. Many are the complaints one hears that the ward was dirty and that the ward manager was unable to do anything about it because he or she was not in the reporting line for the contractor. I hope that arrangements can be made in future contracts for the contractor to be more visibly responsible to the ward manager. That would go some way towards allaying this problem, which seems too dependent on considerations of cost.

NHS: Standards of Care and Commissioning

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Thursday 31st March 2011 Lords Chamber

[Viscount Bridgeman]

My Lords, I congratulate the noble Lord, Lord Turnberg, on his timely and most important contribution. We have benefited from his immense and distinguished experience.

The Health and Social Care Bill represents a once in a lifetime opportunity. However, we must not forget that it is built on, and expands in much greater depth, the fundholder initiatives that existed in the National Health Service between 1991 and 1997, when they were stopped in their tracks by the then Secretary of State. I assure the noble Lord, Lord Turnberg, that that is the last political point I shall make. There were, however, some welcome initiatives introduced by the previous Government, of which two were the creation of foundation hospitals and the introduction of practice-based commissioning groups.

The current reforms under the leadership of my right honourable friend Andrew Lansley seek to build on the reforms of the 1990s and the more recent ones of the previous Government and to capture the advantages and discard the disadvantages of both. At the heart of the Health and Social Care Bill lies the increased emphasis on bringing the patient into the decision-making process, and many of the reforms flow from that. Like, I am sure, many speakers today, certainly the lay speakers, I have canvassed the views of a number of general practitioners and consultants. We can of course differ on the overall measure of enthusiasm for the reforms. However, I think it is fair to say that a substantial proportion of general practitioners welcome the proposed changes, while opinion among consultants is more evenly balanced, though here, among the younger age group, the reforms appear to be generally welcomed.

Among the general practitioners there is the age-old agony for the conscientious GP as to how much time he or she will be required to give up for the management of the consortium, at the expense of treating patients. The evidence from the early experiences of the pathfinder consortia shows that many able practitioners have come to terms with this issue and are able to adjust their professional lives around it—and the consortia are at the heart of these reforms. They will take the place of the primary care trusts. What, then, is the difference? The main difference, as I see it, is that the PCTs have seriously little clinical input. This, by contrast, will, I hope, be the strength of the consortia, which will be clinically led. These consortia, to which every general practice will have to belong, will have the resources to back up their constituent practices and will commission secondary care.

The document Liberating the NHS: Legislative Framework and Next Steps is, I suggest, a model of its kind. It is readable, positive and forward-looking. I wish to speak about one of the specific matters mentioned in it—the provision of specialist services. It is known that some disabled charities are concerned that some specialist low-volume and often expensive services which they use will be lost. The paper specifically provides for this by encouraging consortia to work together to share such services, and for these to be commissioned by the NHS Commissioning Board. This is but one example of the many relatively minor issues which have been addressed in the paper and demonstrates the flexibility of the proposed consortia structure.

Much has been made of pathways in the paper, and these are at the heart of the proposals in the relationship, initially, between the patient and his or her GP. If the patient cannot be treated within the practice, the GP will negotiate with medical colleagues in the consortium, who will in turn negotiate with the provider. Note the clinical input at every stage.

Time does not permit me to make anything but passing reference to the very welcome initiative proposed to combine many of the functions of healthcare and social services under the health and well-being boards. The point that the noble Lord, Lord Turnberg, made about the care of the elderly is crucial to this combination. This is a very important and long overdue development.

I asked a GP who had given me considerable help in preparing for this debate whether there was any point that he would like me to make. He said without hesitation, “The NHS has for far too long tolerated poor performance by general practitioners”. I suggest that this is at the heart of these reforms.