Mental Health and NHS Performance Update

Lord Kakkar Excerpts

Monday 9th January 2017 Lords Chamber

[Lord O'Shaughnessy]

I am grateful to my noble friend for his kind words of welcome. On the specific issue raised on the “Today” programme, which I believe is the subject of a documentary, and how it relates to the Statement made by my right honourable friend, there is an important distinction, which is that it is at the discretion of local clinical leaders. It is not a blanket mandate to delay treatment where the ethical and clinical responsibilities of those treating a given patient require it to be done speedily.

On the issue of the workforce changing, I take my noble friend’s point about what in the education world we called FTEs—full-time equivalents—and will make sure that the workforce figures I use are always expressed in those terms.

[Lord Kakkar (CB)]

My Lords, I declare my interest as chairman of University College London Partners, and join others in welcoming the Minister to his new responsibilities. With regard to the current performance in accident and emergency departments, part of the explanation in the past has been the lack of access to and availability of primary care services. What thought have Her Majesty’s Government given to the potential for the provision of GP primary care services within accident and emergency departments? How is that work going forward and how might it be integrated with the broader provision of primary care services in the community?

[Lord O'Shaughnessy]

I thank the noble Lord for that question; he speaks with a great deal of knowledge and wisdom on the subject. Clearly, to ensure that we have the best possible services, the system needs to be as flexible as possible to local requirements. As is already happening in some areas, having GPs in A&Es as part of the triage, the streaming service, will provide that kind of efficiency and effectiveness, so that everyone is treated properly. I do not have the detail on where NHS England is on that process, but I will be happy to write to the noble Lord with more detail.

Medical Students

Lord Kakkar Excerpts

Wednesday 26th October 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, predicting the future requirement for doctors is extremely difficult. It is more a matter of prophesy than science. The fact that we are now going to fund an extra 1,500 doctor places a year, which is a 25% increase, should make a huge difference.

[Lord Kakkar (CB)]

My Lords, I declare my interest as chairman of University College London Partners. Beyond undergraduate medical education, do the Government believe that there are sufficient opportunities for the established workforce to continue to develop itself to meet the changing needs of the population of our country?

[Lord Prior of Brampton]

That is a very big question, which is hard to answer. My personal view is that I do not think that the training we give to our young doctors in management, leadership and how to structure new models of care is sufficiently broad. You could argue that the curriculum at medical school is too narrow and should be broadened.

NHS: Health and Social Care Act 2012

Lord Kakkar Excerpts

Thursday 8th September 2016 Lords Chamber

[Lord Kakkar (CB)]

My Lords, I join in thanking the noble Viscount, Lord Hanworth, for having secured this important debate and in so doing declare my own interests as chairman of University College London Partners, professor of surgery at University College London and a member of your Lordships’ House ad hoc Select Committee for this Session on NHS sustainability.

We have heard that the Health and Social Care Act 2012 introduced new structures and new organisations to assist in both the commissioning and the delivery of healthcare, but it also put on the Secretary of State for Health, for the first time, new duties with regard to research, education and training in the National Health Service. The research function is vitally important because it is with research and innovation that we are able to develop the novel therapies and technologies that will over time transform healthcare. The duty of the Secretary of State to ensure that this is promoted throughout the restructured National Health Service—ensuring that hospital trusts, primary care and all the other arm’s-length bodies were sensitive to this requirement—is vital. The adoption of innovation will provide the opportunities as we move forward for more precision medicine and, as a result of that, to ensure that personalised medicine will transform the prospects for our fellow citizens and hopefully drive improved clinical outcomes delivered more effectively and efficiently throughout the entire NHS.

Can the Minister say what assessment has been made, since the passage of the Act, with regard to this duty of the Secretary of State? Has the NHS as a whole become more effective and efficient at delivering the research agenda? Has the performance of organisations within the NHS with regard to clinical research improved? As a result of increased research activity, have we seen greater adoption of innovation throughout the system? Are we able to demonstrate that the adoption of innovation at scale and pace, through a variety of health economies, is providing clinical outcomes for patients availing themselves of NHS facilities?

Beyond the question of research, there is the question of education and training, and once again new arm’s-length bodies, by way of Health Education England, were established as part of the Act. There was also a duty placed on the Secretary of State for Health to ensure that education was promoted and that we developed a workforce fit for purpose, recognising over time that the changing demographics of the national population availing themselves of NHS services and the change in the nature of disease that the NHS would have to deal with, with more chronic disease, would require a much more flexible workforce. We need the ability for those committing themselves to a professional career as healthcare professionals to be provided with the opportunities not only to establish themselves at the beginning of their careers but also to adapt and change over time to ensure that they can address the changing needs of our fellow citizens and the NHS itself.

How successful has Health Education England been in achieving those objectives? These were important new obligations and duties on the Secretary of State that provided excellent opportunities to transform the workforce to ensure that it was better able to deliver the changing needs of the NHS.

As part of the discussion during the passage of the Bill, there was much emphasis on ensuring early post-legislative scrutiny of the legislation to ensure that these important objectives were established. I know that in 2014 the Department of Health did undertake some post-legislative scrutiny. The outcome of that demonstrated that the principal provisions of the Act had indeed been established, but beyond that what has been achieved by way of the anticipated outcomes in those two important areas?

We have also heard in this important debate about integrated care and how so much of the purpose of the original Act was to ensure that integrated care could be delivered. This is a vital objective. The fact we will see the need to manage so much more chronic disease over time in the National Health Service demands a different approach to the delivery of care, focused no longer on the boundaries of individual institutions but on understanding the pathways that the large numbers of patients with chronic disease will have to follow—pathways that will require interaction with the hospital sector and with highly specialist centres at some times during their disease’s natural history but predominantly in the community.

One of the concerns raised during the Bill’s passage through your Lordships’ House was whether the bodies charged with regulation of the healthcare system were in a position to determine the quality outcomes achieved through true integrated care, rather than care delivered in institutions. I ask the Minister what assessment the Department of Health has made of the ability of the Care Quality Commission and NHS Improvement to assess outcomes of integrated care packages delivered across hospital and community boundaries, and their performance in terms of their clinical effectiveness and their value to the health economy across those institutional boundaries. As we move to greater integrated care, it is vital that we understand that the systems we currently have in place are adapting themselves to ensure they can assess how quality and efficiency are delivered beyond institutions and in such a way that the investment of valuable healthcare resources in new models of care always delivers the very best for our patients.

We have also heard in this important debate about the vital need to explore further the link between healthcare and social care. Sir Cyril Chantler, a distinguished clinician, in a letter to the Daily Telegraph last month reflected on the fact that in the United Kingdom—in England—it is easy to get into hospital and very difficult to get out. One of the best-performing countries for healthcare in Europe is the Netherlands, where it is very difficult to get into hospital because there is such an emphasis on well-integrated care in the community prior to the hospital stage that they save a huge amount of resource by keeping patients in the community.

In assessing the impact of the Health and Social Care Act and the opportunities avoided by it, what has been demonstrated to date is the need to improve the collective and integrated nature of care in the community prior to hospital admission to ensure that patients might be best managed in the community, rather than admitted to institutions.

Health: Hepatitis C

Lord Kakkar Excerpts

Thursday 28th April 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, this new drug for hepatitis C is made available on the basis of clinical need, not the route of infection. There is a consultation going on about whether a special fund might be established for those who have received infected blood. I cannot answer specifically on the issue of the Welsh people but I will write to the noble Baroness on that matter.

[Lord Kakkar (CB)]

My Lords, I declare an interest as chairman of UCLPartners and Business Ambassador for Healthcare and Life Sciences. What progress has been made on the accelerated access review, which is supposed to be able to address some of these important issues with regard to the adoption of innovation into routine practice in the NHS?

[Lord Prior of Brampton]

The noble Lord makes a very good point. Of course, we hope that the accelerated access review will lower the cost of some of these drugs by shortening the time it takes to approve new drugs. We hope that the accelerated access review will report within a couple of months.

NHS: 111 Service

Lord Kakkar Excerpts

Monday 21st March 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, the decision to stop NHS Direct was, of course, taken in 2008, when I think the noble Lord was in post. He shakes his head, so perhaps he was not, but the decision was taken in 2008, before this Government were in charge, if you like. The new system uses the NHS Pathways algorithms developed by the Royal College of GPs, on which the BMA and the Royal College of Paediatrics and Child Health sit, so we have considerable confidence in the algorithms used. We will also increase the number of clinicians. I accept the noble Lord’s point that we need to have more clinicians answering these calls rather than call handlers, as he puts it. It is our intention progressively to increase the number of clinicians in these 111 hubs.

[Lord Kakkar (CB)]

My Lords, I declare my interest as chairman of University College London Partners. What assessment did the Government make of the training needs of the individuals who were to deliver the 111 service prior to its introduction, and what determination have the Government made subsequently of the appropriateness of that training?

[Lord Prior of Brampton]

My Lords, as I said, the decision to set up 111 was made back in 2008. The operation of 111, which includes the training and the capabilities of the people working in it, is carefully monitored by the CCGs—which commission 111 services by the licence under which 111 operates the NHS Pathways algorithms—and, of course, by the CQC.

National Health Service (Licensing and Pricing) (Amendment) Regulations 2015

Lord Kakkar Excerpts

Tuesday 1st December 2015 Lords Chamber

[Lord Turnberg (Lab)]

My Lords, I must first apologise to the Minister for not appearing at his briefing yesterday and for coming late to his initial remarks. That will not stop me speaking, if I may.

The regulations are clearly designed to save money. They have little to do with correcting what is a major underlying defect in the tariff system: the perverse incentives that tariffs have introduced. My noble friend Lord Hunt has dealt pretty well with how the regulations were aimed at raising the threshold at which objections can be raised and, equally importantly, levelling the playing field to allow small providers with limited budgets to have the same voting power as very large teaching hospitals with billion-pound budgets, which provide more than 95% of the service. It is rather like non-league football clubs and those in the Premier League having the same voice in their commercial activities. The problem is that, to get 66% of all organisations, including all the small ones, puts those trusts that provide more than 90% of the service in hock to those who provide less than 10%. So it is not much wonder that the highly specialised hospitals—the Marsden and Great Ormond Street, the Institute of Neurology, the Christie hospital and so on—are voicing strong concerns about the impact on them. Of course, that is why the Government want to shackle them—to keep costs down—but that is at the risk of denying high-quality specialised care to those who need it.

All that has been well rehearsed by my noble friend Lord Hunt and other noble Lords. I really wanted to point out that the regulations do nothing to get round the unintended consequences and perverse incentives of the tariff system, which I raised with the Minister in a previous debate. That system encourages trusts to go down the route of using devices to gain higher incomes and discourages cross-referral between specialists within a hospital when a trust can gain two fees for two referrals from general practice. It discourages consultants from using phone-in follow-up out-patient clinics to save patients the need to travel in to be seen, as a visit to a hospital incurs a higher fee on the tariff. I agree with the noble Lord, Lord Warner, as he rails against the acute hospitals, but I do not necessarily agree with all his solutions.

I support my noble friend’s amendment. The regulations are unwarranted and damage those who provide the vast majority of the service, while doing nothing to get at one of the major defects in the tariff system.

[Lord Kakkar (CB)]

My Lords, I declare my interest as chairman of University College London Partners, an academic health science centre which has a number of important providers. The Minister made a very important point about the five-year forward view and the need to encourage new models of care working that ensure collaboration beyond institutional boundaries —and, indeed, to go further and look at new models of funding, including those of accountable care organisations. With a view to a potential journey towards more effective commissioning, and therefore more intuitive constructing of a tariff to support general acute services and more specialised services, will the proposals that the Minister brings to the House today aid that journey? Will looking at these regulations in the way proposed help institutions to work more effectively together, recognising the opportunity to look at tariffs that focus on pathways of care rather than individual segments of care, so ensuring the Government’s objective to ensure that valuable resources committed to the provision of healthcare are used most efficiently? There is a recognition that there will have to be greater attention to these matters as we go forward, and every opportunity should be used to ensure that that objective is achieved. One of the most important is the approach to setting the tariff and, therefore, these regulations.

[Lord Prior of Brampton]

My Lords, as always in these debates, we have had some pertinent and useful contributions. I shall take some of the points raised in reverse order. On the very important point raised by the noble Lord, Lord Kakkar, a profound change is happening in how we will deliver care over the next five years, which will be very much more based around a system rather than the institution. I think that the noble Lord, Lord Hunt, would agree with that; we will move from a payment-by-results system that has been very much based around individual pieces of care delivered in acute hospitals, to other payments systems, such as a capitation system or a whole pathway system. That is going to happen.

Mesothelioma (Amendment) Bill [HL]

Lord Kakkar Excerpts

Friday 20th November 2015 Lords Chamber

[Lord Kakkar (CB)]

My Lords, I, too, join noble Lords in thanking and congratulating my noble friend Lord Alton of Liverpool on introducing the Second Reading of his important Private Member’s Bill, and in so doing I declare my own interest as professor of surgery at University College London, an institution with a very active research interest and base in many different cancers.

There is no doubt, as we have heard in this debate, that mesothelioma represents an important burden of disease for our country—there were some 2,500 deaths from mesothelioma in 2013—but also, going forward, it represents a substantial burden of disease in the years to come, with a predicted 56,000 deaths in the period 2014-2044. We have also heard that mesothelioma represents a particularly nasty form of disease with a very peculiar natural history, potentially seen to develop over many decades in an unpredictable fashion, where there is no therapeutic intervention today that can offer a chance of a cure, where diagnosis is often late, and where palliative care, although advancing, still does not provide patients with any meaningful hope of long-term survival.

Under these circumstances, it was quite right for my noble friend to have put forward amendments in Committee and on Report, when the Mesothelioma Act 2014 was passing through your Lordships’ House. I was interested in my noble friend’s proposition on that occasion because there is evidence that the research base on mesothelioma is limited. With a disease that we understand so little about, it seemed intuitive that, using the opportunity of mechanisms made available by the Diffuse Mesothelioma Payment Scheme, an additional levy might provide a base for enhanced research funding in this area. This is important because, without such funding, it is impossible for many researchers to make the long-term commitment to create a group and study a disease over many years or decades, to ensure that advances in understanding are made available. The noble Lord, Lord Winston, made important points in this area.

This is not only a question of research into the specific disease of mesothelioma, but of ensuring that understanding generated in other areas of cancer research, and cell biology more broadly, can be applied to it. There is now an increasing emphasis on understanding that, if we are going to improve outcomes for patients with a variety of different cancers, and other chronic long-term conditions, we need to move away from a generalised approach to managing disease towards personalised, precision medicine: understanding, at a molecular and cellular level, the mutations driving a particular cancer, such as mesothelioma, then developing biological therapies to target them. The problem at the moment is there is an insufficient molecular characterisation of mesothelioma to ensure that this disease can avail itself of all the other advances taking place in research generally.

On 17 July 2013, when the Mesothelioma Bill was debated on Report, as recorded in col. 786 of vol. 747 of the Official Report, the then Minister, the noble Earl, Lord Howe, answered a number of points. As we have already heard, it was argued then that the correct approach was not to ensure more funding for mesothelioma research but that other mechanisms be used to stimulate more research proposals, which would then be funded if they were of sufficient quality. That seemed a reasonable argument. We have heard the four principal mechanisms that were suggested: first, that the National Institute of Health Research convene a workshop of the principal funding charities, such as Cancer Research UK, the Medical Research Council and others—I understand that that took place in May 2014; secondly, that a highlight notice be published by the National Institute for Health Research, identifying this as a priority area for research—this happened in September 2014; thirdly, that a priority-setting partnership be convened—the James Lind Alliance did this with a variety of stakeholder groups in December 2014. Fourthly, it was suggested that the National Institute for Health Research make its research design service available to help researchers come forward with research studies which were properly designed from a methodological point of view and so would enjoy a greater chance of research funding. What progress has been made in each of those areas; what were the outcomes of those four specific initiatives?

In that same debate, in 2013, we heard that MRC funding for mesothelioma had increased from £0.8 million in the financial year 2009-10 to some £2.4 million in 2011-12. Has the increase in Medical Research Council support for mesothelioma research continued on that upward trajectory, or has funding fallen back? How many more applications have been received by the funding councils, by the National Institute for Health Research or the research charities, as a result of the four specific initiatives that were offered to your Lordships’ House at the time of that debate? It would be very reassuring if there were evidence that there have been more high-quality applications; that more groups are coming together to study mesothelioma; and that there is greater collaboration between those dedicated groups and other groups working on more fundamental areas of cancer biology, or other tumours that share a similar characteristic and biology to mesothelioma, such as some of the sarcomas. If that has not happened, the assumption that by facilitating this type of conversation we would see more research is not going to deliver the kick-start in activity that we require. It may therefore be important to revisit the question of a specific levy, providing more funding and greater incentive and reassurance for researchers to come together and focus on this area.

Ultimately, research is about helping patients, and large numbers of our fellow citizens will suffer from mesothelioma in the years to come. If we can provide greater hope that they might have a better quality of life or, indeed, be cured of this disease, through an enhanced research effort, then we should proceed along those lines.

Health: Global Health

Lord Kakkar Excerpts

Monday 26th October 2015 Lords Chamber

[Lord Prior of Brampton]

The Ebola crisis was indeed a wake-up call. There is no doubt that the leading role we play in the WHO is hugely important, so I agree fully with the noble Lord. The work we are doing on antimicrobial resistance is another example of the very important role the WHO can play, as does our Chief Medical Officer, Sally Davies.

[Lord Kakkar (CB)]

My Lords, I declare my interest as chair of University College London Partners and an officer of the all-party group. This report identifies that our country is No. 1 among the G7 nations in terms of the impact of its medical research, as judged by citation impact. How do Her Majesty’s Government propose to ensure that the NHS continues to develop the foundation for that medical research impact?

[Lord Prior of Brampton]

The noble Lord raises an interesting point. Not only are there more citations of research conducted in Britain, but we co-operate with other countries far more than any other country. We also have in the BMJ, the Lancet and Nature the three leading medical and science magazines. The Government are determined to maintain Britain’s position as one of the leading medical research and life sciences nations in the world, and will carry on supporting that industry.

Primary Care: Targets

Lord Kakkar Excerpts

Tuesday 13th October 2015 Lords Chamber

[Lord Prior of Brampton]

My noble friend makes a very good point. There is an increasing and important role for high-street and community pharmacists in delivering healthcare.

[Lord Kakkar (CB)]

My Lords, I declare my interests as chairman of UCL Partners and as UK Business Ambassador for Healthcare and Life Sciences. What strategy do Her Majesty’s Government have to ensure that NHS prescribers can continue to provide innovative therapies and interventions for their patients?

[Lord Prior of Brampton]

The noble Lord makes an interesting point. I do not have an answer to give him today, but perhaps I may reflect on that and come back to him.

NHS: Financial Performance

Lord Kakkar Excerpts

Monday 12th October 2015 Lords Chamber

[Lord Prior of Brampton]

My Lords, it is worth reminding your Lordships that there was considerable consensus around the five-year forward view. I think that the noble Baroness’s party wholly signed up to it and, along with the Conservative Party, to committing £8 billion of extra money to the NHS over the lifetime of this Parliament. We stand by that. The NHS, in its turn, agreed to find £22 billion-worth of efficiency savings, which I think the noble Baroness accepted when she was part of the coalition Government. That is still the situation so I do not think that we need a new settlement. There is a settlement: it is called the five-year forward view and we are fully committed to it.

The noble Baroness raised the issue of integration. I agree 100% with her and it is an essential part of the five-year forward view—the vanguards are based on it. I remind noble Lords that the spending in the UK per capita on health is $3,200. In France it is $4,100 and in Germany it is $4,800. The NHS does a remarkable job in delivering world-class healthcare, which is rated by the Commonwealth commission and other independent agencies as among the best in the world, with considerably fewer resources than any other developed system in the world.

[Lord Kakkar (CB)]

My Lords, I declare my interest as chairman of University College London Partners. What assessment have Her Majesty’s Government made of the potential contribution of accountable care organisations to addressing the need to advance quality outcomes in the NHS and its financial performance?

[Lord Prior of Brampton]

I thank the noble Lord for that perceptive and interesting observation. The accountable care organisation is one whose time has come. A health organisation with a capitated budget is indeed the way forward. It will drive the integration that the noble Baroness was talking about earlier on. It is a key part of this Government’s health strategy to support accountable care organisations.