Health and Social Care Bill

Lord Patel Excerpts

Wednesday 12th October 2011 Lords Chamber

[Lord Patel]

My Lords, I declare an interest in that I hold fellowships of several colleges. As I am going to speak about medical research, I should also say that I am a member of the Medical Research Council and a fellow of the Academy of Medical Sciences—all of which is probably quite irrelevant to what I am going to say.

I agree with my noble friend Lord Winston that much of this Bill is probably unnecessary. However, we have the Bill, and I will try to focus on issues related to it. I thank the noble Earl, Lord Howe, not only for the way in which he introduced the Bill but also for making time on several occasions to meet me to discuss issues that concern me. I am also slightly concerned at the number of hours he has been sitting in his place. I hope that he is doing sitting exercises to avoid deep vein thrombosis.

The Secretary of State, in his keynote speech at the Conservative Party conference, said: “On my watch, the NHS will not be privatised, fragmented or dismantled”. Judging by the huge amount of briefs, mail and e-mails that we have all had, the perception of those who work in the NHS, patients and the public is the reverse. If the reforms are to work, listening to those who work in the NHS and to patients is going to be important.

Advances in diagnosis and treatments in areas such as cell therapy, genomics medicine, molecular diagnostics, regenerative medicine, nano-medicine and focused ultrasound therapy—to mention but a few—will be available probably in the next 10 years. It will be expensive, but it will also require a reconfiguration of health services to take advantage of it as well as better evaluation of the effectiveness of treatments. In some parts of the country patients are already not benefiting from the latest diagnostics and treatment, particularly those relating to cancer. To contain costs, better strategies for public health will be required, including regulation of diabetogenic products marketed in the high streets. The burden of lifestyle and environment-related diseases is huge and increasing: it accounts for nearly 40 per cent of in-patient admissions.

We also need more effective management of patients with long-term conditions, ideally in the community, delivered in an appropriate environment by skilled healthcare professionals. These patients are vulnerable and their experience of healthcare is often variable. I agree with the noble Lord, Lord Crisp, that we have lost an opportunity in this Bill by not having developed a strategy for delivery of treatment for patients with long-term conditions.

I agree that we need change. But is the scale of reforms proportionate, appropriate and timely? Will the many layers of increased administration that the Minister referred to lead to confusion, bureaucracy and increased costs? Some estimates suggest that there may well be between 25,000 and 30,000 people employed in the NHS Commissioning Board, the CQC, Monitor and the 350-odd clinical commissioning groups, none of whom will be involved in the direct provision of patient care. The NHS Commissioning Board alone may have upwards of 5,000 employees.

I turn now to some of the points raised by other noble Lords whose comments I support. Yesterday’s best advice to the noble Earl, as it was put, came from the noble Lord, Lord Willis of Knaresborough. Later I shall have another piece of best advice for today. However, the noble Lord, Lord Willis, was right to say that establishing the health research authority is crucial. I also hope that the Bill will provide stronger support for a duty on all healthcare providers to be involved in promoting clinical research. I will therefore support the amendments tabled by the noble Lord, Lord Willis.

My noble friend Lord Walton of Detchant expressed strongly the need for the UK to be recognised internationally for good medical training. The Bill’s proposals on the role of health education in England and of the regulator of medical education and training, the General Medical Council, cause confusion. Nothing should be done to change national training programmes. I hope that my noble friend Lord Walton will bring forward amendments that others will be able to support.

Equally, the noble Baroness, Lady Emerton, referred to several important issues relating to the training of nurses, nurse support workers, the representation of nurses on national bodies and safe staffing ratios. I will support her amendments. As a clinician, I understand very clearly that good nursing care makes patients better. She also mentioned Cause 231, but I am sure that she meant Clauses 225 and 226.

The strategy for delivering the public health agenda needs to be strengthened. There is a risk that, as currently drafted, the structures will not deliver the improvements that we need. There is also an issue about the public health workforce. I hope to have amendments on that which I hope will be accepted as a way of improving the delivery of the public health agenda.

The Minister referred to public and patient involvement. If the Government are serious, HealthWatch England should be given a stronger voice. It should be an independent body and not a committee of the CQC; it should be represented on the boards of the NHS Commissioning Board, Monitor and the CQC; and it should be well resourced. That is today’s best advice. I will table an amendment to propose that and I hope that the Minister will accept it.

The noble Earl’s key ministerial responsibility is for quality in healthcare, which is defined as effectiveness, patient safety and patient experience. The quality standards developed by NICE will be the key drivers of quality in the NHS. To be effective, they need to be based on the patient’s journey of care, as I learned when developing quality standards myself. The noble Baroness, Lady Jay of Paddington, is not in her place so I will save her blushes. I wrote her a letter on 16 October 1997 and enclosed a paper on behalf of the Academy of Medical Royal Colleges, of which I was then the chair. The purpose of the paper was to establish a three-pronged approach to improving quality of care through the use of quality clinical indicators; a strategy for developing clinical effectiveness and the accreditation of clinical services licensing through peer review; and, to do this, to establish a body called the national institute of clinical effectiveness. I am glad that it survives as NICE.

The quality standards developed by NICE will be the key drivers of quality in the NHS. They need to reflect the patient’s journey of care and to be used by the national Commissioning Board to develop currency—currency which will be used by Monitor to develop tariffs. The tariffs need to be bundled to deliver effective, integrated care that will result in good outcomes. The pricing has to be appropriate, and therefore should be reflected in the tariffs that the commissioners will use to purchase care.

However, I have to ask why there is such a convoluted way of developing tariffs. Why is there the involvement of the national Commissioning Board, Monitor and the commissioners? The NICE quality standards used by the commission could be simplified, and social care could be included.

The quality regulator, the CQC, will be responsible for making sure that the providers of healthcare follow the quality standards, but the methodology will need to be refined. The best way of assessing healthcare and monitoring quality is through peer review, as experience in other countries such as the United States has shown—and in England we also have the example of cardiac and thoracic surgery. The 300 to 350 clinical commissioning groups will use tariffs to purchase care. Good commissioning has been patchy. The Bill is unclear how that will be developed. How will conflict of interest by primary care doctors, as providers of care, and members of the commissioning group be managed? I have an issue with quality premiums—what they will be used for and the criteria for awarding them.

Performance management of GPs as providers of care is also not clear. When will we have a primary care outcomes framework? I hope that GP referral rates will not be used as indicators for quality payments. We already have evidence that for many patients, particularly cancer patients, late referrals produce poor outcomes. The noble Baroness, Lady Royall of Blaisdon, spoke yesterday—movingly and courageously—about her own family experience.

I think that Monitor as a sector regulator has too many tasks that it need not have. However, one task that it should have is as a financial regulator of social care. Healthcare regulation is complicated; it is not comparable to utilities regulation. Evidence presented at a recent seminar showed that successful regulators are simple regulators.

Time does not allow me to comment on other important issues related to competition, choice, integration, the failure regime and reconfiguration, which are important issues. Some of them have already been mentioned by the noble Lord, Lord Warner, who I hope to join with in the amendments that he brings forward. No doubt we shall have an opportunity to discuss this in detail later.

As many noble Lords have commented, this is a complex and large Bill. I hope that the business managers will recognise the need to allow appropriate time for the Committee stage. In common with other noble Lords, my intention is to improve the Bill, make the delivery of healthcare in the NHS better, and build on what is already good.