NHS: Out of Hours Service

Lord Ribeiro Excerpts

Tuesday 26th March 2013 Lords Chamber

[Earl Howe]

My Lords, of course, the results from the Patients Association report are a matter for concern. We are absolutely committed to improving access to GPs and, from 1 April, responsibility for making sure that that happens will pass to the NHS Commissioning Board. We have outlined a clear set of objectives around patients’ experience of local primary care services in the mandate to the board; we have launched marketing campaigns in each of the new NHS 111 areas, which we are confident will facilitate better access to out-of-hours care; and we will publish information regularly, so that patients can see how their practice is performing and feed back to their practice when it is not performing.

[Lord Ribeiro]

My Lords, at a time when nurses are being urged to wash their patients, is it not time that the GP contract was renegotiated so that GPs can be responsible for the out-of-hours care of their patients and, in doing so, perhaps relieve the pressure on our A&E departments?

[Earl Howe]

Increasingly, this is likely to happen, because our changes to the GP contract this year are bound to make sure that GPs think more about long-term integrated care for their patients. The recommendations from NICE underpinned the new arrangements in the GP contract, and my noble friend is absolutely right that that has to remain very squarely in the sights of all GPs.

NHS: Mid Staffordshire NHS Foundation Trust

Lord Ribeiro Excerpts

Monday 11th March 2013 Lords Chamber

[Lord Ribeiro]

My Lords, like other noble Lords, I express my gratitude to the noble Lord, Lord Patel, for introducing this debate so eloquently. I would like to address some of the recommendations in the Francis report that relate to education and training.

Recommendation 155 requires the General Medical Council to set out a standard requirement for routine visits to acute hospitals that train doctors. It asks for postgraduate deans to assume responsibility for managing the process, for royal colleges to support visits and provide relevant specialty expertise, and for the presence of lay and patient representatives on visits—something that the Royal College of Surgeons has done since 2006. Such visits should be co-ordinated with the work of the Care Quality Commission.

There is a sense of déjà vu about some of these recommendations, because before 2005 hospitals were visited regularly by colleges—some would say too regularly. None the less, the purpose of visits was to inspect and accredit training posts. After each inspection, the visiting team met with the chief executive, the medical director and the clinical tutor and talked about any deficiencies that it had found on its visit and the impact that these would have on service provision. Where problems were discovered the trust was advised that a follow-up visit would be required to ensure that the recommendations were implemented.

I was president of the Royal College of Surgeons in 2007 when the college was asked by Mid Staffordshire NHS Trust to undertake an invited review of its surgical services. Our report did not offer “false assurances” to the trust, as it suggested. Rather, the report identified a lack of leadership, an absence of essential protocols, and issues around attitude and the competence of at least one surgeon. These were all issues likely to impact on patient safety and were just the sort of concerns that could have been picked up in the old-style college visits, where face-to-face interviews of trainees were carried out, with the assurance of confidentiality. The trainees were thus able to speak freely about their training and to flag up any concerns they had. That process did not prevent the tragedy of Bristol, but we have learnt lessons since then.

In his evidence to Francis, Mr John Black, my successor as president, said:

“In the course of such a visit the nature of the service would be investigated as much as the training, because we cannot provide a high standard of training unless there is a good service”.

One junior trainee in his final year in accident and emergency medicine, Dr Turner, said that the pernicious effect of the four-hour waiting target created substandard care in the A&E department. Nurses were bullied into moving patients before they breached the four-hour target, often transferring patients to inappropriate wards and some without their medication. Reports of nurses emerging from management meetings in tears were all too common. Dr Turner’s complaints to his educational supervisor in the trust got nowhere. He identified a lack of commitment to education in a department which had only one consultant despite a college recommendation for four. The ability to express concerns to an external visiting body in confidence is essential if whistleblowing on substandard care is to have any effect.

Restoration of properly structured and co-ordinated college visits are long overdue and I welcome recommendation 155, which seeks to link the regulation of hospitals using professionals and the quality assurance of education and training. Triangulating data about the quality of education and the quality of care would help to paint a fuller picture of the patient’s experience in hospital. The first report of the Royal College of Surgeons on Mid Staffordshire in 2007 mentioned a lack of leadership. In his evidence to the House of Commons Health Select Committee on the Francis report on 5 March last week, Sir Bruce Keogh made this observation:

“I have been on the council of the RCS on two occasions and I have watched the leadership organisations of various tribes...and interest groups slowly feeling that they have been relegated to the position of commentators rather than participants”.

My question to my noble friend is: what steps do the Government propose for bringing these leaders back into the mainstream of NHS delivery and how can we ensure that the doctors and nurses rediscover their voices and act as advocates for patients?

Health: Medical Innovation

Lord Ribeiro Excerpts

Wednesday 16th January 2013 Lords Chamber

[Lord Ribeiro]

My Lords, I add my thanks to my noble friend Lord Saatchi for bringing this debate on a matter that is very personal to him. I chair the research panel of the Pelican Cancer Foundation based in Basingstoke. One of our members, Professor Bill Heald, pioneered a new technique for removing rectal cancer in the early 1980s. Total mesorectal excision, or TME, reduces the incidence of a recurrent tumour in the pelvis after surgery. Despite many publications, presentations and lectures on his technique, it was not adopted in the UK. The Scandinavians, however, were more convinced of the benefits, and Professor Heald developed a national training programme with them, which was adopted in the Netherlands, Norway and Sweden in the early 1990s. It became part of routine practice, resulting in improved outcomes for rectal cancer patients. It was to take another 10 years before TME became accepted as a routine procedure and best practice in the UK, despite it having been first pioneered in England.

So how can we speed up the take-up of new procedures? How can we accelerate translational research? In 2007, the national cancer action team and the Department of Health introduced the LAPCO training programme for teaching laparoscopic colorectal surgery. The Royal College of Surgeons promoted and delivered the programme through its new skills centres and, now, through specialist hospitals throughout England. This initiative proved so successful that I was recently asked to give a keynote lecture in the United States to offer our experience of teaching and disseminating laparoscopic colorectal surgery to the surgical community, and our methodology for assessing skills and accrediting competence to practise the procedure. The invitation letter said:

“It is my understanding that the UK has done this in a more proactive and safe fashion than we have in the States”,

an acknowledgment that central direction, as occurred with TME in Scandinavia and now with LAPCO, can produce best practice and innovation.

For a national programme of laparoscopic colorectal surgery for cancer, we will need about 460 surgeons trained in the technique. This is because we have a large NHS caseload, and it is required to meet the NICE guidelines on laparoscopic bowel resection. We currently have half that number. We need to be able to release doctors and surgeons to train innovative procedures. This requires incentives, the support of the base hospital when they have to go away to learn techniques, recognition of their efforts through clinical excellence awards—which I am pleased to say have been reinstated—and other marks of recognition. These efforts definitely show that you can improve the outcome for patients, and the benefit to them is real.

In a report in 2001, From theory to theatre: Overcoming barriers to innovation in surgery, the Royal College of Surgeons recommended that surgical trainees should be encouraged to participate in ongoing research and to work with multidisciplinary teams. With the support of CMO Dame Sally Davies, who was mentioned earlier, the Royal College of Surgeons has committed to funding five surgical trial centres from 2013, with the aim of recruiting thousands of patients for these trials. As surgeons, we are often criticised for not getting involved in randomised control trials; the comic opera referred to as “surgeons trying to do research” perhaps refers to this.

It is necessary today for us to carry out these trials because the number of trials carried out in surgical discipline comprises less than 10% of those done in cardiology. The trials units will provide expertise to develop multi-centre surgical trials, offer technical support and speed up the delivery of clinical trials. As surgeons, we are trying.

In order to speed up the process, from theory to theatre, it is vital that we involve patients in decisions about innovative treatment. Patients must understand the potential risks so that they are able to give full, informed consent. The process for doing this is in place—we have study design, ethical approval and patient involvement—but it needs to be expedited. We all know how long it takes to get approval to start a new trial. It is important that we do not have to wait the length of time that Professor Heald in Basingstoke did to introduce a procedure which has clearly saved many patients’ lives.

NHS: Research and Development

Lord Ribeiro Excerpts

Monday 17th December 2012 Lords Chamber

[Earl Howe]

I agree with the noble Lord. The Government are providing a record £800 million over five years for NIHR biomedical research centres and units as from April of this year. The centres are based within the most outstanding NHS and university partnerships in the country; they are leaders in scientific translation; and they will play an integral part in the life sciences strategy which the Government published last year.

[Lord Ribeiro]

My Lords, may I declare an interest as a surgeon and say that surgical research attracts less than 2% of the total funding that goes into research? There may be those in this House who feel that surgeons just cut and do not actually do an awful lot of laboratory work, but the truth is that research is an integral part of surgery. We are there to bring translational research from the lab to the patient and to produce results, particularly in the field of cancer. I would therefore be grateful if my noble friend could assure me that there will be much greater emphasis on providing support for surgery?

[Earl Howe]

I agree with my noble friend about the importance of surgical research. The NIHR funds extensive research in surgery across a wide range of funding streams. The most recent estimate of its spend on directly funded research relating to surgery was £7.3 million, but that is a rather historic figure which goes back to 2009-10. In February this year, the NIHR issued a call for research on the evaluation of technology-driven implanted or implantable medical devices and decisions will be made on that next March. Twenty million pounds has been invested in the NIHR Surgical Reconstruction and Microbiology Research Centre, which is an initiative between my department, the Ministry of Defence, the University Hospitals Birmingham NHS Foundation Trust and the University of Birmingham. I hope that my noble friend will agree that that is a positive development.

NHS: Women Doctors

Lord Ribeiro Excerpts

Tuesday 6th November 2012 Lords Chamber

[Earl Howe]

My Lords, there is no evidence that there is a problem with female recruitment into the health service. Indeed, the male-to-female gender balance over the past few years has decreased from 1.83:1 in 2001 to 1.25:1 in 2011. However, I recognise that we should not be complacent. Even with the increased participation of women in medicine, we appreciate that more can be done to improve the selection of senior doctors into senior positions.

[Lord Ribeiro]

My Lords, I declare an interest as a member of the committee chaired by the noble Baroness, Lady Deech. In 1998, I introduced the first job-sharing scheme for female trainees in London and Essex. This involved two girls who both had children and managed to complete their training before the 48-hour week was introduced. What efforts are the Government making to encourage job-sharing and less than full-time training?

[Earl Howe]

My Lords, the Government fully support flexible working. We encourage organisations to take account of the recommendation made by the noble Baroness, Lady Deech, on that subject and adopt working arrangements that are amenable both to doctors who are parents and doctors who are carers.

NHS: Definition of Exceptional Case

Lord Ribeiro Excerpts

Monday 2nd July 2012 Lords Chamber

[Earl Howe]

My Lords, I hasten to reassure the noble Baroness that I have every sympathy with the individual in question, and I was aware of this particular case. The chief executive of the NHS will shortly be writing to her clinical tutor to suggest a possible way forward. However, I should put on record my view that the commissioner is acting reasonably in insisting that its decision on exceptionality should depend solely on the clinical need of the patient, and not on any broader social factors. If there is now good clinical evidence to support the use of this particular treatment, commissioners should be considering whether to make it available to all patients with similar clinical needs, and not just to a few individuals.

[Lord Ribeiro]

Is my noble friend aware that the pancreatic unit at Leicester is not able to do any islet cell transplantation operations because the PCT refuses to fund them? The excuses used to justify not funding these operations are that these may be “procedures of limited value” and “experimental surgery”. There are, in fact, four clinical units throughout the UK doing islet cell transplantation, with good records and good outcomes. I want to know whether the PCTs are not funding these operations in order to present a clean sheet to the incoming CCGs in April 2013, or whether there is another reason.

[Earl Howe]

My Lords, no, that is not the reason. My noble friend is quite right that this treatment has been around for a little while. However, it is not yet in mainstream practice. It is expensive, it is not routinely available in the NHS, and indeed NICE has published interventional procedure guidance which concludes that it,

“shows some short term efficacy, although most patients require insulin therapy in the long term”.

That does not seem to me to be a resounding endorsement of this treatment.

Tobacco: Control

Lord Ribeiro Excerpts

Tuesday 19th June 2012 Lords Chamber

[Earl Howe]

My Lords, if we are successful in our strategy to reduce smoking rates significantly, an inevitable consequence will be that, over time, less and less tobacco will be sold. It is smoking that we aim to reduce, which will have consequences for the sale of tobacco products. For the good of public health we are trying to arrive at a point where there is no smoking in this country, and that would mean no retail sales of smoking tobacco. Hence I fully support the remarks of my right honourable friend the Secretary of State.

[Lord Ribeiro]

My Lords, I am grateful to my noble friend for acknowledging the harm and damage that smoking does. Can he assure the House that the Government are equally determined to ensure that smoking will not have an adverse effect on children and children’s health in the future?

[Earl Howe]

The need to reduce and, we hope, eliminate the uptake of smoking by young people is one of our top priorities. I would like to thank my noble friend for his Private Member’s Bill, which will certainly enable this issue to benefit from a wide airing. We would all like to see smoking in cars with children eradicated—the health of people can be harmed by second-hand smoke. The key question for us at the moment is what is the most appropriate and workable way of protecting children from second-hand smoking. No doubt we will debate that matter when we come to my noble friend’s Bill.

Health: Pancreatic Cancer

Lord Ribeiro Excerpts

Monday 23rd April 2012 Grand Committee

[Lord Ribeiro]

My Lords, I declare an interest as a retired general surgeon who previously operated on patients with pancreatic cancer but was wise enough to give way to more specialised surgeons of this condition.

I support the development of pancreatic cancer centres, as suggested by the noble Baroness, Lady Morgan of Drefelin, because these 28 specialist centres in the British Isles are endeavouring to improve the standard of care for patients with pancreatic cancer. However, there are marked variations between the centres, and their outcomes should be the subject of a national audit.

I join others in thanking the noble Lord, Lord Aberdare, for bringing this debate, in this short time, to highlight some of the problems that exist. The cardiothoracic surgeons have shown the way by their national survey, over many years, of cardiac surgery outcomes. For the second year they have published the National Thoracic Surgery Activity and Outcomes report. It is important that all specialist associations take part in an audit so that it is possible to compare the outcomes between different centres and, frankly, highlight the ones that are good enough and those that are not good enough, so that at least those who know that they fall outside a 95 per cent confidence limit will improve their practice, find out how to do it better, or perhaps desist, as I did.

The argument for centres undertaking large-volume surgery is now accepted, but this needs to be underpinned by proven expertise, and I would say it takes years to actually develop that, within teams, to come up to the standards. It also needs to be underpinned by good research. Resection rates as high as 20 per cent, with 2 per cent mortality, are achievable in some centres, while others report mortality of 14 per cent.

A German study found that cancer cells in the liver and bone marrow appear in some 36 per cent to 76 per cent of patients. Undetected, these patients may well be subject to surgery, only to develop recurrent disease later. Does my noble friend the Minister acknowledge that we need greater investment in research beyond the current 1 per cent of overall cancer research funding, as suggested by the noble Lord, Lord Aberdare?

Exciting new modalities involving genomics, gene therapy and immunotherapy to complement neoadjuvant therapy are in development and need support. Let us be clear: pancreatic cancer is a difficult and complex cancer. Unlike the one-stop-shop diagnosis that can be achieved for breast cancer—which, by the way, is a very visible and obvious cancer—it can take up to six weeks to investigate and diagnose pancreatic cancer in patients prior to surgery.

Commissioners of health need to understand that this is not a cheap cancer, and they need to negotiate with the providers of healthcare and make sure that the complexity and cost are taken into account when managing pancreatic cancer.

I hope that my noble friend the Minister will use the current anti-smoking campaign to draw attention to the 70 per cent increased risk of developing pancreatic cancer among smokers as compared to non-smokers.

Health and Social Care Bill

Lord Ribeiro Excerpts

Tuesday 13th March 2012 Lords Chamber

Moved by

[Lord Ribeiro]

256: Clause 236, page 236, line 29, at end insert—
“( ) But provision made under subsection (8) may impose a requirement on a local authority, or a description of local authorities, only if the requirement relates to—
(a) the exercise by an authority of any of its functions under section 2B or 111 of, or paragraphs 1 to 7B or 13 of Schedule 1 to, the National Health Service Act 2006;(b) the exercise by an authority of any of its functions by virtue of section 6C(1) or (3) of that Act;(c) anything done by an authority in pursuance of arrangements under section 7A of that Act.”

[Lord Ribeiro]

My Lords, I shall speak also to Amendment 257. I have tabled the two amendments for the following reasons. The Bill makes provision for local authorities to fund public health drugs and treatments. It also enables provision to be made for the replication of the funding direction to require the NHS to make available funding for NICE-recommended drugs and treatments. However, as currently drafted, the provisions in Clause 236 to enable replication of the funding direction for NICE-recommended drugs and treatments currently exclude their application to local authorities. Subsections (8) and (9) make provision to enable replication in regulations of the effect of the funding direction that currently requires PCTs to make funding normally available for drugs and treatments that have been recommended by NICE technology appraisal guidance. The amendment would permit other bodies that fund public health services to finance these suggestions as PCTs are phased out of the system, creating a more uniform and streamlined system for patients to manoeuvre through the different health services offered.

As the Bill currently stands, it is impossible for regulations to require local authorities—which take on health functions under new paragraphs (a), (b) and (c) in my Amendment 256—to comply with NICE recommendations to fund such proposals. While these local authorities are likely to be responsible for the funding of such treatments under their public health functions, without codification of their ability to do so in the Bill, there will be no authority to take over the funding of such recommendations to which PCTs remain currently obligated, thus creating a gap in care as health functions are transferred between PCTs and local authorities.

Furthermore, as enshrined in the NHS constitution and its accompanying handbook, NHS organisations are also required by a direction from the Secretary of State to finance drugs and treatments suggested by NICE which are based on sound research evidence. Although the funding direction concerns mainly high-cost drugs or treatments used in NHS secondary care, there have been two or three NICE appraisals that concern public health drugs and treatments. For example, NICE has appraised and recommended a smoking cessation drug, Champix—noble Lords will know of my interest in smoking—which is currently covered by the funding direction. To ensure that this gap in funding does not occur, my amendments would extend the scope of the regulation-making power, enabling requirements to be placed on local authorities exercising their public health functions so that the effect of the funding direction which currently applies to NHS organisations could apply also to them. It is important to note that, while local authorities will have the ability to fund NICE recommendations, this extension relates only to matters dealing with public health. Moreover, regulations will be unable to place a requirement on local authorities to comply with or have regard to NICE recommendations relating to social care, putting limitations on the funding capabilities of local authorities.

--- Later in debate ---

[Earl Howe]

My Lords, I am grateful to my noble friend Lord Ribeiro for tabling these amendments, which address the important issue of ensuring that patients have consistent access to appropriate and cost-effective drugs, whether a service is commissioned by the NHS or by local authorities.

As the House will know, NICE’s technology appraisals provide important recommendations on the clinical and cost-effective use of medicines and other technologies in the NHS. The funding direction that applies to recommendations in NICE technology appraisals has helped to ensure equity of access to NICE-recommended drugs and treatments wherever patients live in England.

While technology appraisals are perhaps most commonly associated with specialist drugs or interventions used or initiated in NHS secondary care, they also make important recommendations about drugs and interventions for use in other care settings, including preventive interventions. In future, these are likely to fall within the scope of local authority commissioning responsibilities for public health. My noble friend mentioned the example of Champix. He is right: technology appraisals could address drugs to aid smoking cessation and treatments to tackle substance misuse.

I agree with my noble friend that extending a funding mandate to NICE-appraised drugs or treatments commissioned by local authorities would bring important benefits. It would guarantee patients access to appropriate and cost-effective drugs, whether a service was commissioned by the NHS or by local authorities. In doing so, it would protect patients’ existing rights as set out in the handbook to the NHS constitution, to which he rightly made reference. I am very pleased that I am able to support these amendments and I hope that your Lordships will feel able to support them as well.

[Lord Ribeiro]

My Lords, I thank my noble friend the Minister for accepting the amendments. I thank also the noble Lord, Lord Beecham, for his kind words.

Amendment 256 agreed.

Health and Social Care Bill

Lord Ribeiro Excerpts

Thursday 8th March 2012 Lords Chamber

[Baroness Murphy]

The noble Lord may be right. If the change in wording applies to how the management behaves but makes no change in clinical priorities—the noble Lord, Lord Kakkar, said that it would not interfere with clinical priorities—I would support it. It is necessary to ensure that management acts like that, as long as it does not cut across the clinical priority that the sickest person comes first, whether private or NHS.

[Lord Ribeiro]

I have one question for the noble Lord, Lord Phillips of Sudbury. I agree with the comments made about management. When I worked as a surgeon, during a period when we were desperate to get patients into hospitals because we had already completed our NHS quota of work by January and had from January to April to make money, pressure was often placed on us as consultants by management to bring private patients into the NHS so that we could make the income. I hear “Oh!” from the other side. However, one problem that came from separating and withdrawing private beds from the NHS was that most consultants have established private practice in private hospitals outwith the NHS. The point that the noble Baroness, Lady Finlay, made was that part of the reason for removing or adjusting the cap and why she supported earlier amendments was to try to get integration of care to allow consultants to be on the spot.

The amendment refers to NHS foundations trusts. As we know, there are trusts that are not foundation but ordinary. What would apply to them? Would they therefore be free to undertake private work in a way that has been described here? This refers only to NHS foundation trusts.

[Lord Campbell-Savours]

I want to intervene briefly because we want to vote on these matters today. The amendment subtly gets to the problem at the heart of the Bill, which totally underestimates the new pressures that will build up within foundation trusts on management to change the nature of the patient body that comes into the trust for financial reasons. The noble Lord who has just spoken in many ways let the cat out of the bag. Pressures are exerted on clinicians by management to take actions that they do not necessarily want to take. If a trust is building up a substantial body of patients referred to it by insurance companies, it will want to be sure that within that trust’s operation some element of priority is given to its patients if only to minimise the liability that the insurance company has to the patient to pay their bills. In 10 years’ time, when the Government review the Bill, they will find that the pressure on management to change what happens in hospitals will lead to the beginning of the destruction of the National Health Service as we know it.