NHS: Performance and Innovation

Lord Allan of Hallam Excerpts

Thursday 15th June 2023 Lords Chamber

[Lord Allan of Hallam (LD)]

My Lords, I am very grateful to my noble friend Lord Scriven for creating the opportunity for this important debate and for introducing it so well. I can also call him my noble neighbour, as we were previously both elected representatives in Sheffield. In fact, we are so neighbourly that the places in our pantomime names—the “of wherever” bit that we get in our formal titles—are adjacent to each other: Ecclesall in my case and Hunter’s Bar in his, for those aficionados of Sheffield neighbourhoods.

The theme of the debate invites us to consider the current challenges and potential solutions, and I will try to do that in my remarks. There are various ways to describe the state of health and social care in this country. Words such as “crisis” are in common use. Naturally, there is a party-political element to the choice of adjectives that we use, with those in government tempted to play things down and those in opposition to talk them up. In the spirit that my noble friend set out of trying to be more objective in this debate, I will try to use some factual descriptions of the current state of affairs, deliberately avoiding emotive language, that I hope will resonate on all sides of the House.

First, it is clear that health and care services are not meeting many people’s reasonable expectations. Too often, they find that they cannot access services that they believe are necessary for their well-being. In some cases, the services are not available at all, while in others they are there but only after an excessively long wait.

Secondly, and related to the access question, we do not have enough people employed in health and care roles to provide timely services of all kinds in all parts of the country. Many services depend on people having skills honed through years of education and practice. If the right staff are not there, these services simply cannot be delivered.

Thirdly, and related to the staff shortages question, there is poor morale in many parts of the health and care system, which is making it much harder to retain staff and affecting the motivation of those who choose to soldier on. The facile response to the morale question is to say that we should stop talking the service down, but that is to miss the point that there are genuine concerns about pay, work-life balance and career progression, which would affect any worker in any sector. Health and care workers are not immune.

It is possible to both praise the service and its staff and to raise concerns that it is not currently meeting the legitimate needs of its workforce. The focus of the Government has to be to address all these foundational issues, ensuring that supply can meet patient demand, building up the right skilled workforce and creating the right conditions to motivate staff.

Members of this House rightly raise questions in all of these areas across the broad range of health and care services each week. We will continue to press the Government until we see them deliver real improvements. Even if they deliver real improvements, we will want to keep on pressing them because we do not want them to feel complacent and because long-term demographic changes mean that, whoever is in government, they will need to keep running just to stand still and will need a super-human effort to get ahead of the curve.

This brings me to a fourth assertion and the one I want to focus most of my remarks upon: we will fail to deliver the healthcare that people need and deserve without introducing significant innovation into the NHS. That has been the theme of so many contributions today. However, this has to be the right kind of innovation. It is not an alternative to increasing investment in health and care but a complement to it.

There is a saying that if you only have a hammer then everything looks like a nail. To reinforce the point made by the noble Lord, Lord Crisp, I think about structures and legislation, and the hammer that we have as politicians is to pass more laws. We have seen successive Governments seeing innovation in Bills that create new structures for health and care but do not necessarily deliver wider innovation than the structure. We can all hope that these structural reforms will deliver. I know the current Government place a lot of store in the integrated care board model that is currently bedding in. However, the fact that restructuring happens repeatedly suggests that it is not enough to deliver the upgrade we need. The noble Lord, Lord Turnberg, reminded us that more can be done through better integration. That happens in some parts of the country but it is not spreading everywhere.

Others have spoken about a range of areas of potential innovation, which I hope the Minister will agree are worth exploring. My noble friend Lord Addington was right that we need to think about how health and care is dealt with across government. Departments considering things such as our sports, education or environmental strategies equally have a role to play in promoting health and care. Other noble Lords have brought other areas of expertise to bear. The noble Baroness, Lady Bennett, talked about the environmental challenges and some potential opportunities.

It is apparent that there is no shortage of ideas for how we could innovate our way to better health and care outcomes, but there seem to be systemic barriers to ensuring that innovations are taken up across services. I think that has come out in this debate, where we have heard that some of the examples of good practice are isolated examples rather than things which have become standard practice.

Like other Members of the House, as I was preparing for the debate I was contacted by a range of organisations that are thinking about innovative solutions in diabetes care, ophthalmology, cancer research, virtual wards—the list goes on. It is great that we have those ideas, but in this debate we need to think about why those ideas are not becoming standard practice. I was also fortunate to participate in a round table recently organised by someone who advises me, Peter Lacey of the Whole Systems Partnership. He brought together experts in different fields across health and care to pitch excellent ideas for how we might make real changes. I was impressed by just how much thinking there is out there.

We also read every week of projects bringing in new technologies such as AI. I accept fully my noble friend Lord Scriven’s point that it is not all about the technology but about the people, and again, we see these instances of pilot projects. I was reading just this week about the use of AI to detect breast cancer in Aberdeen. We are told that this can make a huge difference today, yet I fully expect when I read those stories that, in a year’s time, those projects will still be isolated to the particular trust that has brought them ahead.

I have a particular interest in how the innovative use of information technology might create step-change improvements. I want to introduce some of those ideas into the debate, but not because they are the most important. I am fascinated by examples such as that of the community health visitor that the noble Lord, Lord Crisp, raised. All those things are fascinating but it is sometimes helpful to talk about the things you know about the most. In my case, I have some expertise in information technology.

To be very clear from the outset, this is not about building more apps but primarily about ensuring that data and information can flow between people and services in ways that will add the most value to all parties. If noble Lords are interested in the argument for why we should focus on good service structure and design rather than just building more apps, I recommend an article from as far back as 2013, by Tom Loosemore, that the Government Digital Service called We're not ‘appy. Not ‘appy at all. It recommended that the Government hold back on seeing the solution as simply another app on your phone. Anyone who deals with the NHS will find, as I have done, that they have a whole folder on their phone of the different apps that different parts of the NHS have told them they must use to contact them. Some are good, some not so good, some get integrated and some do not, but it is not about the apps; it is about the flow of the data.

In the spirit of bringing positive ideas to the debate, an example of the kind of tool that is going in the right direction is a service called Patients Know Best. Other noble Peers may benefit from it if they live in the right parts of the country, because I understand that it is available only in certain health trust areas. This provides patients with immediate access to test results, with helpful contextual information so that, when they have a blood cholesterol test, they can see the result as soon as it is processed by the lab and go and get information about what that result means for them. These kinds of services should be standard practice everywhere; if someone has a test done then there should be secure online access to the results as a matter of course. Yet as I said, I understand that my access to that service is dependent on the part of London I live in, and people who live further down the road may not have access to it. I am curious about the Minister’s thoughts on why services such as these are not universally available.

The second innovation that has potentially huge value is the development of trusted research environments for health data. It is often said that a fortunate by-product of the fact that we have a unified NHS is that data about health activity and outcomes is more consistently available than in other countries, where it might be scattered across small and competing providers. Although we have our own issues in relation to how usable the underlying systems are, our unified national structure provides a good starting point in being able to pull together large-scale datasets.

One of these research environments is the OpenSAFELY.org project, which provides access to GP data not by taking it and sending it off somewhere else but by having infrastructure in the data centres of the main GP record providers so that researchers can access that data securely. We should be making more use of services such as that, having built them. I understand that it is not the universal access method; there are still plenty of people doing research using alternative methods and we have yet to get to a point where the innovation has become standardised.

That brings me to my final point, which overarches all of these areas—tools such as those patient tools and trusted research environments, but also good practice, such as community health visitors and other examples that have been raised. It is the question of how we ensure that innovation spreads. The way innovation spreads through the NHS at the moment is neither fish nor fowl. There has been a reluctance to dictate from the centre, under the assumption that market forces are somehow necessary to drive innovation, yet we do not see the best products and services winning as we would in other markets.

By way of an example, look at how the smartphone market developed; it was ruthless. Products from former giants such as Nokia, BlackBerry and Microsoft were beaten into submission by services from Apple and Android, the services that we all use today. There are bigger questions about competition that stand outside this debate, but the outcome we have seen there is the ubiquitous adoption of some very capable devices. By comparison, it can feel as if some parts of the NHS are still running on Nokia and BlackBerry while others are running ahead with their much better smartphones, and that produces very uneven outcomes. One thought I would like to leave the Minister with is whether there needs to be a different form of central direction to make sure that innovative services and models are delivered more rapidly.

At Oral Questions earlier we had a very good Question from the noble Lord, Lord Crisp, about a palliative care service developed in Derbyshire, and the Minister said, “We want all ICBs to do this”. It sometimes feels as if there are plenty of carrots on offer but insufficient sticks. What happens when a service is available, when we know that the technology is there simply and easily to introduce something such as immediate access to blood tests, but some parts of the country are not choosing to adopt that? What mechanisms may be used to encourage—and, to go further, require—that take-up to happen?

Again, I point the Minister to previous examples in which the Government Digital Service has existed not just to produce standards and say, “Here are the standards; go and do it”, but has had strong political support and would use much more persuasive measures to get different parts of government to adopt the latest thinking around digital. That is not exclusive to digital; it is a much broader question.

There is a need for a real sense of urgency in rolling out innovations in the health service, whether in technology, people, drugs or delivery models, if we are to have any chance at all of getting aligned with, never mind ahead of, the demand curve. I believe the Minister shares that sense of urgency. Perhaps he is not yet institutionalised enough to have given up on the idea that rapid change is possible. I hope that today he can offer us some glimmers of light that might encourage us to believe that change is possible. Again, I thank my noble friend and neighbour Lord Scriven for creating the framework for this interesting debate.