NHS: Reform

Lord Prior of Brampton Excerpts

Thursday 16th July 2015 Lords Chamber

[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

My Lords, with the leave of the House, I will now repeat a Statement made in another place by my right honourable friend the Secretary of State for Health. The Statement is as follows.

“With permission, Mr Speaker, I would like to make a Statement on measures to improve the safety culture in the NHS and further strengthen its transition to a modern, patient-centric healthcare system. The failings at Mid Staffs detailed in the Francis report were not ‘isolated local failures’. Facing up to widespread problems with the safety and quality of NHS care and learning the appropriate lessons has been a mission which the Government and the NHS have shared, with a common belief that the best way to deal with problems is to face up to them, rather than wish they did not exist.

Measures taken in the last Parliament include introducing the toughest independent inspection regime in the world, more transparency on performance and outcomes than any other major healthcare system, new fundamental standards, a duty of candour and the excellent recommendations made by Sir Robert Francis QC. But because the change we need is essentially cultural, a long journey still remains ahead. The Department of Health was described during the Mid Staffs era as a ‘denial machine’. We therefore have much work to do if we are to complete the transformation of the NHS from a closed system to an open one, from one where staff are bullied to one where they are supported, and from one where patients are not ignored but listened to.

So today I am announcing some important new steps, including our official response to Sir Robert Francis’s second report, Freedom to Speak Up; our response to the Public Administration Committee report, Investigating Clinical Incidents in the NHS; and our response to the Morecambe Bay investigation. I am also publishing the report of the noble Lord, Lord Rose, into leadership in the NHS—a key part of the way we will prevent these tragedies happening again. I would like to thank everyone involved in writing those reports for their excellent work.

In his report, Freedom to Speak Up, Sir Robert Francis QC made a number of recommendations to support this cultural change. All NHS trusts will appoint someone whose job is to be there when front-line doctors and nurses need someone to turn to with concerns about patient care that they feel unable to raise with their immediate line manager. We will also appoint an independent national officer, located at the Care Quality Commission, to make sure all trusts have proper processes in place to listen to the concerns of staff, before they feel the need to become whistleblowers. Other changes will include information about raising concerns as part of the training for healthcare professionals and curriculum for medical students, as well as a greater focus on learning from reflective practice in staff development.

Dr Bill Kirkup’s report into Morecambe Bay brought home to this House that there can be no greater pain than for a parent to lose a child and then find that pain compounded when medical mistakes are covered up. We will accept all of the recommendations in this report, including removing the Nursing and Midwifery Council’s current responsibility and accountability for statutory supervision of midwives in the United Kingdom and bringing the regulation of midwives into line with the arrangements for other regulated professions.

Likewise, we agree with the vast majority of the recommendations of the excellent report of the Select Committee on Public Administration into clinical incident investigations. In particular, we will set up a new independent patient safety investigation service by April 2016, based on the success of the ‘no blame’ approach used by the Air Accidents Investigation Branch in the airline industry. It will be housed at Monitor and the TDA, which have the important responsibility of promulgating a learning culture throughout the NHS. Monitor and the TDA will operate under the name ‘NHS Improvement’ and Ed Smith, currently a non-executive board member of NHS England, will become the new chair, with a brief to appoint a new chief executive by the end of September.

For NHS managers, the report of the noble Lord, Lord Rose, Better Leadership for Tomorrow, makes vital recommendations to join up the support offered to NHS managers, to improve training and performance management and to reduce bureaucracy. He extended his remit to cover the work of clinical commissioning groups, which play a key role in the NHS, and today I am accepting all 19 of his recommendations in principle, including moving responsibility for the NHS Leadership Academy from NHS England to Health Education England.

These are important recommendations, which, in the end, all share one common thread: the most powerful people in our NHS should not be politicians, managers, or even doctors and nurses—they should be the patients who use it. Using the power of intelligent transparency and new technology, we now have the opportunity to put behind us a service where you ‘get what you are given’, and to move to a modern NHS where what is right for the service is always what is right for the patient.

A litmus test of this is our approach to weekend services. Around 6,000 people lose their lives every year because we do not have a proper seven-day service in hospitals. You are 15% more likely to die if you are admitted on a Sunday, compared with being admitted on a Wednesday. This is unacceptable to doctors as well as patients. In 2003-4, the then Government gave GPs and consultants the right to opt out of out-of-hours and weekend work, at the same time as offering significant pay increases. The result was a ‘Monday-to-Friday’ culture in many parts of the NHS, with catastrophic consequences for patient safety. In our manifesto this year, the Conservative Party pledged to put this right, as a clinical and a moral priority.

So, I am today publishing the observations on seven-day contract reform for directly employed NHS staff in England by the Review Body on Doctors’ and Dentists’ Remuneration and the NHS Pay Review Body. They observe that some trusts are already delivering services across seven days, but this is far from universal. According to the DDRB, a major barrier to wider implementation is the contractual right of consultants to opt out of non-emergency work in the evenings and at weekends, which reduces weekend cover by senior clinical decision-makers and puts the sickest patients at unacceptable risk. The DDRB recommends the early removal of the consultant weekend opt-out, so today I am announcing that we intend to negotiate the removal of the consultant opt-out and the early implementation of revised terms for new consultants from April 2016. There will now be six weeks to work with the BMA union negotiators, before a September decision point. We hope we can find a negotiated solution, but are prepared to impose a new contract if necessary. To further ensure a patient-focused pay system, we will also introduce a new performance pay scheme, replacing the outdated local clinical excellence awards, to reward those doctors making the greatest contribution to patient care.

I am also announcing other measures today to make the NHS more responsive to patients. These include making sure patients are told about CQC quality ratings, as well as waiting times, before they are referred to hospitals, so that they are able to make an informed decision about the best place to receive their care. NHS England will also develop plans to expand control to patients over decisions made in maternity, end-of-life care and long-term condition management, which I will report in more detail subsequently to the House. Finally, because the role of technology is so important in strengthening patient power, we must ensure no patient is left behind in the digital health revolution. I have therefore asked the noble Baroness, Lady Lane-Fox, formerly the Government’s Digital Champion, to develop practical proposals for the NHS National Information Board on how we can ensure increased take-up of new digital innovations in health by those who will benefit from them the most.

When we first introduced transparency into the system to strengthen the voice of patients, some called it ‘running down the NHS’. In fact, since then public confidence in the NHS in England has risen 5 percentage points. By contrast, Wales, which resisted this transparency, saw public satisfaction fall by 3 percentage points. Over the last Parliament, the proportion of people who think the NHS in England is among the best healthcare systems in the world increased by 7 percentage points; those who think NHS care is safe increased by 7 percentage points; and those who think they are treated with dignity and respect increased by 13 percentage points. This demonstrates beyond doubt the benefits of an open, confident NHS, truly focused on learning and continuous improvement.

But as we make progress in this journey, we must never forget the families who have suffered when things have gone wrong—in particular, the families and patients at Morecambe Bay and Mid Staffs, the whistleblowers who contributed to Sir Robert Francis’s work and everyone who has had the courage to come forward in recent years to help reshape the culture of the NHS. Without their bravery and determination, we would not have faced up to the failures of the past, nor been able to construct a shared vision for the future. We are all massively in their debt; this Statement remains their legacy and I commend it to the House”.

My Lords, that concludes the Statement.

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[Baroness Walmsley (LD)]

My Lords, I, too, thank the Minister for repeating the Statement. It reflected much of what I heard this morning from the Secretary of State at the King’s Fund. It is a brave and realistic approach but there are some yawning gaps in it compared to what I should have expected in a major statement about NHS reform. However, I welcome several points.

The focus on culture change and nurturing staff is absolutely right. The NHS is the best and most cost-effective service in the world only because of the skills and commitment of its staff, yet we are told that in some places staff morale is poor. This is very sad to hear. It was good to hear earlier this morning about the beneficial effect on morale in those hospitals that are responding positively to being put in special measures.

I welcome the new personnel, processes and training that are being put in place to ensure that staff can safely express concerns about the quality of care, so that each member of staff can take part meaningfully in the improvement pathway of his organisation. We could do with ditching for all time the expression “whistleblower” with all its negative connotations. I welcome what the Secretary of State called “intelligent transparency”, a no-blame focus on what went wrong and how to put it right. In common with the noble Lord, Lord Hunt of Kings Heath, I think that merging the TDA and Monitor could be a good thing, with this focus on no-blame improvement. That should help, but we still need more signposting for patients and service users about how and where to complain if they have poor care in what is a very complex system.

I of course welcome the focus on better data-gathering, especially in the field of mental health, where we are rather short of it. Managers cannot make good financial decisions without the facts about what everything costs. Businesses could not survive like that and neither can the NHS.

I welcome the long-awaited publication of the Rose report and the acceptance of its recommendations. I look forward to seeing what they are. We need a new focus on the quality of NHS management. If we are to rise to the challenge of the £22 billion of efficiency savings, we need excellent managers and finance directors as well as excellent doctors and nurses. I welcome the fact that the noble Lord, Lord Rose, extended his remit to CCGs.

I also welcome the new requirement for hospitals and groups of doctors to provide a seven-day service but I share some of the concerns of the noble Lord, Lord Hunt, about how it will be delivered. People do not get sick to order just on weekdays, so that is important. I should, however, like assurance that this does not necessarily mean putting any further burden on individual hard-working doctors, nurses and laboratory staff. Good planning is needed to avoid further burdens. However, this will certainly mean the recruitment of more trained staff. We need assurance that they are in the pipeline. Can the Minister say, for example, what the Government are doing to stem the flow of staff, trained by the NHS at a cost to the taxpayer, who leave the country as soon as they qualify?

What was missing from the Statement and the speech this morning was context and understanding that filling the £30 billion black hole in the NHS requires a whole-Government response. If patients are to be in charge, they need good health education so that they know what a healthy lifestyle means. They need access to sports and leisure facilities and nutritious food, and they need warm, dry homes. Integration needs to be a lot broader than just integration between health and social care. Unless social care is properly funded, the NHS will not be able to find its expected £22 billion of efficiency savings while making the improvements outlined in the Statement because of the knock-on effect on acute hospital beds. Yet while there has been more money for the health service, there has been nothing but cuts in social care.

The thrust of the Statement was about getting it right first time and, if not getting it right the first time, then certainly the second and subsequent times. This has to be right for patient safety and confidence but also for cost-effectiveness. If we are to rise to the increasing demand on the health service, we must get it right as near as possible every time and we must support the staff in doing so.

[Lord Prior of Brampton]

My Lords, I thank the noble Lord and the noble Baroness for their comments. I was quite depressed listening to the noble Lord opposite. We had a debate in this House last week and we talked about a sense of political consensus on the NHS. I start by saying—rather personally—that, having listened briefly this morning to his right honourable friend Andy Burnham in the other place misquote me out of context from the debate that we had last week, I thought that there was no hope of a non-partisan approach to the NHS. For the avoidance of any doubt from anybody, and as I think I made pretty clear in last week’s debate, I believe fundamentally and passionately in a universal, tax-funded healthcare system—the NHS—that is free at the point of delivery and based on clinical need, not ability to pay. Having looked back on it, I do not remember uttering a word in that debate that would question that statement. Therefore, I hope the noble Lord opposite might have a word with his right honourable friend in the other place to make it absolutely clear that playing cheap party politics has no place in our discussions about the NHS.

Turning to the comments about my right honourable friend the Secretary of State for Health’s Statement today, seven-day services are in many ways at the heart of it. Thousands of people are dying because we do not provide seven-day services in hospitals. We cannot carry on with a system with thousands of people dying. It is not just that thousands of people are dying. The health of thousands of people is deteriorating in our hospitals over the weekend.

This is an anecdote, which may be unfair. However, two years ago, I met a radiologist walking down the corridor in an NHS hospital on a Friday morning. His wife had been admitted through A&E. She had abdominal pains. He could not get her a scan. She was going to have to wait in that hospital until Monday. Had it been a bank holiday, she would have had to wait in that hospital until the following Tuesday before she had that scan. That is an anecdote, but we know that it is happening all the time. It is unacceptable.

So I ask the noble Lord opposite to be more enthusiastic about this. Of course it will be difficult. This Government are putting in £8 billion of new money. This is more money than his party was prepared to offer before the election. It is the same amount of money that the noble Baroness’s party was offering to put in. This is £8 billion of additional money that we are putting into the NHS. It is a critical part of our strategy. It was laid out in our manifesto and is in the NHS Five Year Forward View that we would make seven-day services a main plank of these reforms. For those people who think that this cannot be afforded, put yourself in the position of a chief executive of an NHS hospital that works four and a half days a week because theatres stop work at lunchtime on Friday. Often, they do not start again until Monday lunchtime because every bed is taken up when they come in to work on Monday morning. Across the country, thousands of consultant surgeons, theatre staff and anaesthetists are hanging about on Mondays because they cannot start their work. This is because there is not a bed in the hospital because the flow of patients through that hospital came to a grinding halt on Friday. The noble Baroness is right that this is not just a hospital issue but about joined-up care. You cannot get the discharges out of the hospital unless social care, the physios and the OTs are working—the whole system needs to be working. Seven-day working is not only right for patients but will enable our hospitals to work much more efficiently.

I will pick up a few other issues. I remember when the 2003 contract was voted on by consultants. In my view, it was a disastrous contract, which deprofessionalised many professional consultants. They voted against it the first time and voted for it, grudgingly, only the second time. They voted for it because their pay went up by 28% as a result of it and they could opt out of providing care over weekends and outside normal hours—of course they voted for it. Looking back on it, some of the noble Lords and Baronesses opposite will maybe accept that it was a disastrous contract. It deprofessionalised a deeply vocational profession and fundamentally changed the culture of the NHS—a culture that we are now trying to change once again.

I welcome the comments of the noble Lord and the noble Baroness about Sir Robert Francis’s report on whistleblowing. We want an open culture, in which whistleblowing is a thing of the past. I agree with the noble Baroness that whistleblowing is not a great name. It would be great if we never heard about whistleblowing ever again because people felt able to raise their concerns in a proper, central and safe way and knew they could raise them without fear of any detriment to their employment prospects. The proposals put forward by the Public Administration Select Committee, which have been taken up by the Secretary of State for Health, are absolutely right. We need a safe place for when things go wrong.

I turn to the Rose report. Leadership is fundamental. Around a hospital, one ward will be doing well and one will not because there is a good ward sister in the first one; one hospital will be doing well and one will not because of good local leadership in the former. Leadership is absolutely fundamental, and I subscribe to all the comments that my noble friend Lord Rose has made in his report.

The noble Lord’s comments about the TDA and Monitor are harsh. David Bennett and others in those organisations have done a very good job in very difficult circumstances. We are fundamentally changing the roles of TDA and Monitor. Together, they are now, as the name suggests, an improvement agency first and a regulator second. The new role of the TDA and Monitor in NHS improvement will fundamentally change the way we approach performance management and improvement. The Secretary of State for Health alluded to the contract that the TDA recently signed with Virginia Mason, one of the safest hospitals in the world, which is one way of bringing best world practice into the NHS.

I will conclude on the context. Times are difficult in the NHS and we should not pretend differently. This Government are absolutely committed to seeing this transformation programme through. The noble Lord opposite said he did not know anybody who thought that we could achieve the £22 billion in savings that are set out in the NHS Five Year Forward View—he knows me.

[Baroness Blackstone (Lab)]

My Lords, I declare an interest as the chairman of the Great Ormond Street Hospital Foundation Trust. Before I put my questions to the Minister, I will just make one brief comment on his remarks about the Opposition. I have no idea what the shadow Secretary of State for Health said in another place, but I will defend what my noble friend Lord Hunt has just said. He said that he agreed in principle with a great deal of the Statement, but it is legitimate for the Opposition to ask questions about how a Statement of this sort might be implemented, which is what he was doing.

I have two questions, the first about bureaucracy. The Minister said that he wished to see a reduction in bureaucracy. As a chairman of a trust, I entirely identify with that. However, some of the bureaucracy is in the regulators, and I hope that his attack on bureaucracy will cover the regulators. The Government are about to set up another outside agency, which will put further bureaucratic pressure on those who are delivering services upfront. Anything he can do to try to reduce that would be helpful.

My other question concerns seven-day services. Again, I entirely endorse what the Government wish to do with respect to seven-day services—if anything, they are overdue—but there are questions to be asked. What is the timetable for this, if it is only going to apply to new consultants? It will take a very long time to introduce seven-day services if only new consultants are going to go on to the new contract requiring them to work at weekends. I understand why the Government are doing that, but it will make for a very long delay. What steps will the Government take to try to encourage existing consultants, who will be far greater in number than the flow of new consultants, to adjust to a new approach where seven-day services are introduced in the interests of patients?

[Lord Prior of Brampton]

I can only agree with the noble Baroness on bureaucracy. The new body that we are setting up to look at incident reporting, as recommended by the PAC, will only look at big incidents so will not be an added bureaucracy for the day-to-day running of a trust. I am always struck by the figure that nurses spend only between 70% and 80% of their time dealing directly with patients because they are dealing with bureaucracy. The bureaucracy argument falls into two parts: it is partly about the way hospitals run their affairs and partly about external regulators. We believe fundamentally in intelligent transparency. I see the CQC, for example, as less a regulator and more a means of providing intelligent information to boards of hospitals and to patients. But I take on board what the noble Baroness says. We will do everything we can to reduce the level of bureaucracy.

As far as the timetable is concerned, junior doctors will switch over much more quickly than consultants, because they turn over much more quickly. It will take time for consultants to move over to the new contract, but we hope that we can make it more attractive to consultants and that it will be more of what I would call a professional contract, so that existing consultants will switch over to it as well as new consultants. We will have to watch that very carefully.

[Baroness Finlay of Llandaff (CB)]

The way that the Minister has been speaking has made it sound as if the majority of consultants do not work on weekends, and I question the validity of that. The consultants who are on and on call are dealing with emergencies at the weekend and are very often in. However, without diagnostic back-up, without physiotherapy and occupational therapy, without specialist nurses and without community services to which they can discharge patients, they effectively have to function with one hand tied behind their back—sometimes both. You cannot provide modern medicine without that broader team. If you are going to free up hospital beds, you have to be able to discharge patients safely, knowing that they will have the care they need. The 24 hours post-discharge is when patients are at their most vulnerable.

I will question one thing the Minister said. He gave a six-week timeframe for the BMA. Does that also apply to the NHS Pay Review Body negotiations? What will be done to make sure that all the other staff also move on to contracts that will provide that infrastructure, right through from operating department staff to, as I said, allied healthcare professionals and so on?

The Statement referred to end-of-life care. Could the Minister inform the House when there will be a response to the report What’s Important to Me. A Review of Choice in End of Life Care, which was undertaken for the National Council for Palliative Care? I declare an interest as its incoming chairman. It has been submitted to the Department of Health, but there has still not been a response to it, even though it has been universally welcomed by both providers and patient groups.

My last question relates to digital innovation. I welcome the fact that the noble Baroness, Lady Lane-Fox, with her tremendous skills, will be brought in. What are the Government’s targets and how rapidly are they planning to roll out digital innovations? Will they undertake in the process to decrease the paper-load bureaucracy, so that staff can be freed up to deliver front-line patient care, and are not caught by risk-averse processes and procedures that force them to spend a lot of time in documenting or double-checking, when the evidence base for that improving patient care is extremely thin?

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[Lord Prior of Brampton]

The noble Baroness raises a number of points. Of course, she is right that it is no good just having senior doctors in a hospital without the right back-up, particularly diagnostic specialist nursing. She has just mentioned OTs and physios, and I agree with her completely there.

The noble Baroness mentioned the NHS pay review. There is not an opt-out clause in the Agenda for Change contract. Discussions will be taking place with the RCN and other trade unions later this year. I will have to write to her about the timing of the response on the end-of-life care point that she raised; I do not know it offhand. Digital information will be rolling out progressively over the next five years. I certainly hope that we will have electronic patient record in place for the vast majority of patients over the lifetime of this Government.

[Baroness Browning (Con)]

I welcome my noble friend’s announcement—I hope that he will take some cheer from that. I have too often been an emergency admission at a weekend and know only too well that if you have to wait to see the consultant on Monday you simply end up bed-and-breakfasting for two or three nights in hospitals. I hope that my noble friend will take into account how having a consultant available for those sorts of patient would save a lot of money, free up a lot of beds and achieve what he is describing.

I know that Ministers do not like to micromanage what goes on in hospitals, but with the transition to new contracts for new consultants, I hope that my noble friend will find a way to identify those particular disciplines in hospitals where there are more deaths—he mentioned this—so that attention can be given to consultants with new contracts in those disciplines. An aortic aneurysm needs a consultant standing by the patient, but with other easily identifiable conditions it would be good if the Government could make sure that hospitals proactively recruit consultants on new contracts to ensure that the 6,000 deaths that he mentioned come down as rapidly as possible.

[Lord Prior of Brampton]

I was interested by my noble friend’s comments about waiting until the following Monday when she has been in hospital. That is a good illustration of why we want to bring in seven-day services. My noble friend might be interested to read the report in Future Hospital, written by the Royal College of Physicians, that came out a year ago. I think that we will see over the next few years a significant change in the way that our hospital consultants are trained and deployed, and more generally what is called in America hospitalists, who can have a broader range of disciplines.

When it comes in, the new contract will enable us to differentiate payment for those consultants who are working more anti-social hours, such as A&E consultants who will have to work much more regularly out of hours than others. It will enable us to identify those consultants who may be on call but are more likely to be summoned in, like those that my noble friend just mentioned, at short notice. Depending on the surgical specialty, the on-call requirements can be much more demanding than others. For example, this is more the case if you are a vascular surgeon than if you are a dermatologist, who do most of their work in normal time. I take on board what my noble friend says.

[Lord MacKenzie of Culkein (Lab)]

My Lords, no one will disagree with the concept of a seven-day-week health service. I was at the wrong end of a catastrophic surgical error that meant instead of one night in hospital I was there for six months. I dreaded weekends, and I dreaded them even more if there was a bank holiday attached, as has already been mentioned.

If we want to deal with party politics, can I explode the myth that has been peddled that the Labour Government were responsible for the five-day-week approach, because of the consultant contract? For many years I was a theatre nurse. I never scrubbed on a Saturday or a Sunday in the 1960s or 1970s. Hospitals ran on a five-day-week then, so it is quite wrong to suggest that this is all the fault of the consultant contract a few years ago.

I agree with my noble friend Lord Hunt of Kings Heath. If we want to have endoscopy suites open, radiography, radiologists, and nurses manning theatres and recovery rooms on Saturdays and Sundays, we must have more of these professions. If we do not, we shall diminish them on Mondays, Tuesdays and Wednesdays, and we will not be much further forward. Will the Government commit to increasing training places for all of these professions, together with consultants such as radiologists, as I suspect that we have many fewer of those than in most other developed countries?

[Lord Prior of Brampton]

Interestingly, the number of consultants has increased very significantly over the past 15 years across not all but most specialities. The noble Lord refers to dreadful weekends, and how he dreaded them, particularly bank holidays. That is really why we are here today, so that in future patients like him do not dread them.

If I indicated earlier on that I blame the 2003 contract for the difference between five days’ and seven days’ working, and if that was the implication of what I said, I withdraw it. What I meant to say was that I felt that that contract to some extent de-professionalised the profession.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, most people will welcome much of what is in the Statement.

I would like to come back to the issue of seven-day working that in principle this side supports and accepts. Some of the problems that we have at the moment in the NHS are the top issues with patients. We keep talking about patients being “top of the tree” and being in charge. Can the Minister tell the House what issue about NHS performance at the moment disturbs patients most of all? We have a list of issues where we are doing well: tell us what is worst.

The worst is the inability to access a GP, on a timely basis, five days a week, not seven days a week. This is not new. The position was bad in 2010, when Labour, my party, was in power, but it deteriorated while the Lib Dems and the Conservatives were in the coalition. I can point to Questions in Hansard raised in 2012, when we were promised by the noble Earl, Lord Howe, that discussions were taking place in the profession about trying to improve access to GPs, particularly where there were problems in London. I speak as a patient with a GP in London, who asks how he is to provide a seven-day week service when he cannot get the GPs and does not have the money to do it.

My noble friend Lord Hunt asked a basic question which is of prime concern to people, particularly in London. Will spreading this over seven days until such time as you can provide the 5,000 trained GPs who were promised, which will be seven years down the road, lead to a further deterioration in the ability to access a GP during the week?

[Lord Prior of Brampton]

There is no doubt that, looking forward over the next five years, the resource to be put into primary care will be greater, relatively, than it has been in the past. We wish to deliver more care outside hospital. That is why we are committed to training and having in place 5,000 more doctors in general practice by the end of this Parliament—not just GPs, but others who will support GPs.

The model of primary care will change significantly over the next five years, and it is fundamental to the five-year forward view that we reduce the number of people going into acute hospitals and that we discharge people at the other end of their journey through an acute hospital much quicker.

[Baroness Tyler of Enfield (LD)]

My Lords, I welcome the principle of working towards a weekend service—indeed, I think it is hard not to—but I certainly do not underestimate the difficulty of achieving it, particularly in a fully joined-up way. This morning, I attended a meeting with many children and young people who had experienced a serious mental health crisis at the weekend and had real difficulty accessing the treatment they needed. Indeed, some of them had turned up at A&E but there had simply been no mental health services available for them. In the light of that, will the Minister reassure me that the principle of seven-day working will apply to consultants from mental health disciplines, particularly those treating children and young people whose access to those services seems to be even harder to secure than it is for adults? Secondly, the Statement talked about CQC quality ratings as well as waiting times being made accessible to patients. Will he confirm that these will include waiting times for mental health services?

[Lord Prior of Brampton]

The Government are committed to parity of esteem, and if we are truly committed to parity of esteem the answer to both the noble Baroness’s questions must be yes. We must have the same standards for physical health as we have for mental health. If someone has a psychotic crisis on a Friday afternoon and they cannot get access to any help until the following Monday, that is clearly extremely poor care. If they end up in an A&E department being looked after by people who have no experience of dealing with mental health problems, it is a very poor environment to be in, so I agree entirely with the noble Baroness.

[Lord Turnberg (Lab)]

My Lords, I, too, welcome the Statement and many of the things in it. We accept that higher mortality rates at weekends in hospital are unacceptable, so we have to try to think of ways of reducing them. Seven-day working for consultants is just one element. Consultants are important, of course. The Minister is probably aware of Brian Jarman’s publication some years ago which showed that there was an inverse correlation between the number of doctors in a hospital and the mortality rate; that is, a hospital with more doctors had a lower mortality rate. There are lessons to be learned there, especially as we in the UK seem to have fewer doctors per head of population than almost any other OECD country, and fewer beds come to that—so we are starting from a low ebb, and the points made by noble Lords about where we are going to get the extra people from are important.

However, the consultant element is just one part. The noble Baroness, Lady Finlay, made a very good point about the need for radiologists, physiotherapists and pathology laboratories. All the machinery of the hospital has to be there. Equally, there is the whole business of general practice and community care. Primary care at the weekend is poor, by and large; that is one of the major problems. Patients are not getting into hospital until they are in greater extremis, so they are more ill when they get there: then they require more service, and once they are there, they cannot get home because there is no one to see them home. Concentrating on consultants is just one element. What is the Minister’s response?

[Lord Prior of Brampton]

The noble Lord, Lord Turnberg, knows the situation on the ground as well as anybody in this House and, of course, he and the noble Baroness, Lady Finlay, are absolutely right that this will not be solved just by having more consultants in acute hospitals. We have to look right the way across social care, primary care, community care, mental health care and acute care. We are talking about a system. In many ways, one of the reasons why we find ourselves in the position we find ourselves in today is that we have not had a system for some time. We have deliberately broken up the system for good reason.

I was very much in favour of foundation trusts having their own balance sheet and their own profit and loss account because of increased accountability, but disadvantages have flowed from that. Chief executives in acute hospitals look after their own. They have treated themselves as an island. We are not part of an island. Rebuilding the system will take some time. It is not going to happen tomorrow, and there is no silver bullet. All I can say is that the Government are committed to the five-year forward view, the new models of care and joined-up care. We are committed to experimenting with accountable care organisations, integrated care organisations and all kinds of joined-up models. We are seeing exciting developments in Manchester and possibly, in time to come, in Cornwall and other parts of the country where we will have pooled budgets between social care and healthcare. I am confident that over the next five years we will if not solve these problems, at least go a long way to doing so.