Health and Social Care Bill

Lord Ribeiro Excerpts

Monday 7th November 2011 Lords Chamber

[Lord Walton of Detchant]

My Lords, 53 years ago, after seven years in full-time clinical research followed by 18 months as a first assistant in a neurological department with an honorary senior registrar contract, at the age of 35 I was appointed as a consultant in the NHS. But since at the time I had not even reached a salary of £2,000 a year, on being appointed as a consultant I chose to take a maximum part-time contract to do limited private practice, if only for financial reasons. In fact, it was a very interesting experience. I did this only for a few years before I became a full-time academic.

At that time every NHS hospital had a private ward or had the opportunity, as was the case in the regional neurological centre in Newcastle Upon Tyne, such that on my ward of 28 beds I was entitled, if I so wished, to use four single rooms for private patients. The advantage of that arrangement, which was widespread throughout the country, was that the consultants working in that kind of hospital had the right to be geographically whole-time at the hospital. They were not being diverted away to distant private hospitals. They could look after their patients, both private and public, on the same ward and give them equal standards of care. The only real advantage for the private patients was that they had single rooms.

Many years later, along came Barbara Castle, who was the Secretary of State for Health and who later became the much respected Lady Castle. By that time I was a full-time academic with no private practice. I took private patients under my care into hospital, as I had to do if they came from overseas. In order to take advantage of the research facilities in my department, they had to be treated as private patients. However, under pressure from the trade unions, the Government worked through a process of gradually removing private patient beds from NHS hospitals so that, in the end, in the three major hospitals in Newcastle Upon Tyne we had one private bed in each hospital. The result was that, as an academic with major research facilities for the investigation of neuromuscular disease, I had to refuse patients referred to me from the United States, Canada, Australia and elsewhere because there were no private hospitals which could provide the facilities needed for the investigation of these patients, and there were no private beds into which they could be admitted. I look back on the period before that, when there were private beds in NHS hospitals, with great interest. I think that it was an excellent arrangement.

This is why I strongly support the proposal that the cap on private patient beds in NHS hospitals, foundation trusts and so on be removed, but I agree that there should be a restriction so that the opportunity for such beds to be established for private patient care must not be excessive. However, the advantage is that the NHS will gain substantially from the income derived from those private beds. The noble Lord, Lord Phillips, has enunciated the principle that the standards of clinical care for public and private patients in those hospitals should be entirely comparable. The only advantage for private patients would be a better standard of accommodation, as Amendment 299B indicates, which is wholly acceptable. The quality of medical care should be identical. For that reason, I support the principle.

On the other hand, the wording of Amendment 30 is not satisfactory. Although I accept the principle of equal standards of clinical care, the amendment would make it impossible to provide the improved standards of accommodation to which Amendment 299B refers. The principle is important and I would support it in general, but the amendment needs a little adjustment.

[Lord Ribeiro]

My Lords, I agreed with everything that the noble Lord, Lord Walton of Detchant, said. His historical perspective reflects my own experience, both as a young trainee working at the Middlesex Hospital, where we had a separate private wing, and then post the decision made by Mrs Barbara Castle when the private wings lost their beds. The net result was that, when I became a consultant in 1979, there were very few private beds in my own hospital. I was a maximum part-time consultant as well. We saw a proliferation of new private hospitals in Brentwood—the Nuffield—Chelmsford and Southend; the whole area sprouted new private hospitals. I would see my private patients at the beginning of the day and then again at night while fulfilling my NHS commitment, which I am quite happy to say I did. I could travel 100 miles in a day seeing private patients, whereas previously those patients were in the same hospital. The junior doctors knew where the consultants were and if there was a problem on the ward they could consult them and bring them back.

There is another dimension to moving private beds out of the NHS, which is that I used to be able to take my trainees with me to the private hospital to assist me with my operations. That was a level of learning that they would often not have the opportunity to access, particularly if it was related to overseas patients with conditions that they had not previously seen. It was a learning opportunity which is now more or less lost. Junior trainees are very rarely able to escort their consultants to work in the private sector.

As to the private cap, it will not surprise your Lordships that two big hospitals in London, the Royal Marsden and Great Ormond Street, have a massive number of private patients who seek treatment from those hospitals because they are the best in the world. A cap in that situation is against the best interests of those hospitals. Robert Naylor, the chief executive of UCLH, has been quoted as saying that it is entirely transparent where the money from private patients treated in the NHS goes: back into supporting services within the NHS. Maintaining the cap on private earnings in the NHS will damage the NHS. Patients who come in to have their treatment privately in the NHS are treated by consultants who treat both NHS and private patients. There is no difference between the two. To deny those hospitals the opportunity of attracting patients from overseas and the benefits going back to the NHS would be a disservice.

I have looked at this amendment and, clearly, the intention is to ensure equality of care. I was watching the monitor upstairs in my office and heard the introduction to this debate. I am sorry that I was not here. The meaning behind the amendment is right. There should be equality. I am not sure whether it can be achieved in the way that has been described. The noble Lord was quite right in saying that the clinical treatment—this is not about food, beds or those sorts of facilities—that is provided should be the same.

Health and Social Care Bill

Lord Ribeiro Excerpts

Wednesday 2nd November 2011 Lords Chamber

[Lord Ribeiro]

My Lords, I am very pleased to—I am sorry; I know how difficult it is for my noble friend. Would he like to go ahead?

[Lord Newton of Braintree]

I am sorry but I am really quite slow in standing up, as noble Lords will observe.

I do not want to take a huge amount of time. I am not a member of the Alderdice-Patel-Hollins club and I will therefore not attempt to go down their professional path. I am, however, for the moment at least, a member of another club in that I chair a mental health trust—the Suffolk Mental Health Partnership NHS Trust—so I have an interest to declare. I want to express my strong general support for the basic thrust of these amendments, whatever the wording: to emphasise, in the words of the Government’s White Paper, “No health without mental health”. We need to ensure that mental illness is treated with parity in these matters, so far as we can.

I will make only another couple of observations. First, it is worth remembering that one of the notorious pressures on A&E departments at the moment is people turning up with mental illness problems, in effect, and needing the attention of mental illness specialists. This spills over and crosses the boundaries. I still think it right that there should be separate mental health trusts, but we need to recognise these linkages. Secondly, we need to recognise that this is an area in which integration with social services is particularly important. Integration is key because of the extent to which mental illness services are provided not in hospital but in the community and on a combined operation. As an aside which we will return to, the CQC needs to improve its act in terms of assessing community services for the mentally ill, which in my view it is not at present sufficiently equipped to do. That is a point we shall come back to. My main point is strong support for the principal thrust of these amendments, which I hope my noble friend will feel able to accede to.

[Lord Williamson of Horton]

My Lords, briefly but warmly, I support Amendment 11, which seems to me to be desirably explicit and logical in the structure of the opening clauses of the Bill. It is desirably explicit because, while I am sure that the Minister actually wants continuous improvement in the quality of service in connection with the prevention, diagnosis or treatment of physical and mental health, those words do not appear in Clause 2. There remains in the wider public some feeling that mental health has a lower priority than physical health. I believe that there has been a huge improvement in the priority given to mental health—I have a lot of experience of that because of my family circumstances—but the feeling I have referred to exists. Therefore, to be explicit on mental health in this clause is good.

The amendment is logical in the Bill because under subsection (1) of the new clause in Clause 1:

“The Secretary of State must continue”,

to promote,

“a comprehensive health service designed to secure improvement … in the physical and mental health of the people of England”,

yet we do not have that phrase in Clause 2, where we come on to,

“improvement in the quality of services … in connection with … the prevention, diagnosis or treatment of illness”.

That directly contributes to what is expressed in Clause 1, so we need to carry over that phrase and avoid its omission in Clause 2. That is why I support this amendment.

[Lord Ribeiro]

My Lords, I will be brief on this. I strongly support the amendment because it is important to recognise that mental health and acute clinical health go hand in hand. Most hospitals throughout the country started with psychiatric services outwith the main hospital buildings. Over many years we have tried desperately to integrate the service. We no longer have the concept of the psychiatric Bedlam that was the case in the past.

For the last five years or so of my clinical practice, a rotation of junior doctors came to work for me. They would spend four months on general medicine, four months on surgery and four months on psychiatry. As a consequence, I learnt quite a bit about psychiatry, although I am not sure that they learnt an awful lot about surgery. That was an example of integrated care. The importance of it is that a lot of the acute psychotic and suicidal admissions to hospital come through the accident and emergency department. They do not come through the separate door of a psychiatric unit at the other end of the hospital or in a different block. They come to the acute part of the hospital.

I am not saying that the Bill team necessarily overlooked this but, as has been pointed out by the noble Lord, Lord Williamson, if proposed new subsection (1)(a) is to refer to the Secretary of State’s duty to and responsibility for “physical and mental health”, it stands to reason that, as is currently the case, the Secretary of State delegates responsibility for the provision of the health service to the strategic health authorities and PCTs. Their successor bodies will be the national Commissioning Board and the clinical commissioning groups, so it stands to reason that those two bodies must also have responsibility for mental and physical health. It is vital that the three major groups who have responsibility for the health service in this country—the Secretary of State, the NHS Commissioning Board and the clinical commissioning groups—should all have a responsibility to deal with these two areas of healthcare, because they form part of an integrated service.

[Lord Layard]

My Lords, some years ago I had a meeting with a newly appointed Secretary of State for Health, although he was not that newly appointed—he had been there for three weeks. At the end of our conversation about mental health, he said, “You know, I’ve just realised something. I’ve been in this job for three weeks, I’ve had about 50 meetings and this is the first time I’ve heard the words ‘mental health’”. That says it all. That is how our health service is run and, unfortunately, how the priorities are set. I should just like to review four key facts to show why this is not at all satisfactory.

First, according to the official survey, one in six adults suffers from mental illness, mainly clinical depression or crippling anxiety disorders. These are serious conditions, as has been said. For example, a very good WHO study compared the debilitating effect of depression with that of angina, arthritis, asthma and diabetes. Depression is at least 50 per cent more debilitating than those conditions. That is why half of all the disabled people of working age in our country are disabled by mental illness. It is not a small segment but a massive chunk. It is the largest illness among people of working age.

However, coming to my second point, only a quarter of those who are mentally ill are in treatment, compared with more than 80 per cent of those with the kind of physical illnesses that I mentioned. Last year the chairman of the Royal College of General Practitioners wrote to his members with the question: if you have a patient who needs psychological treatment, can you get it normally, sometimes or rarely? Only 15 per cent said “normally”. That is the situation that we are in, which is shocking. The treatments that are available are good. They are recommended by NICE but simply not delivered on a proper scale, even though they are meant to be delivered according to the NICE guidelines.

Thirdly, what is even more extraordinary is that these are cheap treatments. It is quite easy to show from the experience of the Improving Access to Psychological Therapy programme, for example, that they completely pay for themselves through savings on out-of-work benefits, lost taxes, unnecessary visits to the GP and unnecessary references to secondary care. However, if we ask what commissioners’ priorities are, these treatments are of lower priority than many of those for physical conditions that are often much less disabling.

Finally, what is so extraordinary about this, as other speakers have said, is that the problems of people with mental health difficulties also rebound on their physical condition. We also know that many physical conditions rebound on mental conditions. Many physically ill people—those suffering from angina, lung disease or a stroke, for example—suffer from depression. Several proper clinical trials show that, with proper psychological treatment of these mental conditions, the physical condition will improve to the extent that all the money is, again, repaid in savings in physical care. Therefore, we should give much more priority to these conditions.

We also see cases where people are referred with physical conditions that have no physical explanation. Something like half of all referrals to the secondary sector fall into that category of medically unexplained symptoms. Again, many of those will respond to psychological treatments.

Despite all this, we all know where mental health stands in the priorities of commissioners. It counts if there is a serious risk of homicide or suicide. Then they really get to it. However, if not, it is, unfortunately, the easiest area to cut, which is happening on quite a scale at the moment. Two years ago the regulator, Monitor, recorded the fact that mental health services are cut by more than physical health services whenever there is a shortage of money. Monitor recorded this in its advice to trusts on how to budget in the future; it was part of its guidance. It is invariably the case that mental health is cut more than physical health when there is a shortage of money. It is just extraordinary. That guidance was eventually recanted but it is the reflex throughout the commissioning world. I am making the point that this is not only important but a very big thing. That is why it is important that we include the phrase “physical and mental illness”, and do so from the beginning of the Bill. If we do not, people will tend to forget mental health, as the department did for three weeks when it was briefing the then Secretary of State. I urge the noble Earl to take this amendment very seriously.

Health and Social Care Bill

Lord Ribeiro Excerpts

Tuesday 25th October 2011 Lords Chamber

In the case of prescribing, the patient wants something done and will not be told that there is nothing to be done to help him, but the poor old GP does the best he can, so he writes another prescription. If noble Lords have ever had to clear up after an elderly relative who has died, they will have discovered in the medicine cabinet loads of prescribed medicines that were never taken, never used. As my noble friend Lord Rea said, I am not suggesting for one moment that the health service is perfect, but this Bill is not the way to remedy that kind of deficiency. So I have two hopes: first, that my noble friend divides the House on this issue, because it is so fundamental that we really ought to hear the voices as to who goes one way and who goes the other. I also hope that enough noble Lords vote for this amendment so that we can start as best we can to rescue the health service that we love.

[Lord Ribeiro]

My Lords, I am grateful to my noble friend Lord Mawhinney for referring to the words, “motherhood and apple pie”, because when I first saw this amendment, that is the way it looked. When one reads proposed subsections (1), (2)—or parts of it— (4), (5) and (6), they seem pretty innocuous. However, in proposed subsection (2), we are talking about high principles, which none of us would disagree with—principles which crop up time and again throughout the Bill. Quality—something that the noble Lord, Lord Darzi, referred to in a speech a few weeks ago —equity, integration, accountability are all points that we will address in the coming weeks, and are fundamental aspects of this Bill. However, the phrase “not the market” is not a principle—it is a mechanism for delivering what one wants.

The noble Lord, Lord Peston, said that any form of market would turn the NHS into a privatised industry. May I remind him that during the time of the previous Administration, we had independent sector treatment centres? What were they if not an example of a market-driven industry? They were introduced—

[Lord Peston]

I was not a Minister in that Government, so I do not have to defend them.

[Lord Ribeiro]

At least the noble Lord recognises that it was something that happened, and that it was a market. It was deliberately introduced by the previous Government. Were it not for the fact that NHS consultants were excluded from working in that area, it achieved the objective it was designed to do, which was to reduce waiting list numbers. However, it was a market, so if we were to accept proposed subsection (2), we would effectively say that we must call an end to all forms of privatised healthcare provision that currently exist in the NHS. I think that noble Lords would agree that this would not be acceptable.

Proposed subsection (3) talks about restructuring and reorganisation. The noble Baroness, Lady Williams, addressed this very effectively when she said that we do not want to encapsulate the NHS in aspic, creating rigidity rather than flexibility. The previous time the House debated the health service, I made reference to the decision that had been made on Chase Farm. It had taken 17 years for it to be made. If we were to accept proposed new subsection (3), effectively every constituent of Chase Farm would have a very good legal reason to challenge why that reorganisation had taken place. While I am fully supportive of the idea in Amendment 52 of having the NHS constitution clearly laid out—we all agree with, understand and support it—I am not in agreement that the five principles as set out in Amendment 1 should be accepted in their present form. If it came to a vote, I would certainly oppose the amendment.

[Lord Bichard]

I have some sympathy with the suggestion that we should set out at the beginning of the Bill the values and principles on which the service is based. My difficulty is that I fear the amendment is not appropriate or adequate in its current form. Therefore, I will be unable to support it for reasons that other noble Lords have given, and for two others in particular.

First—and others may find this provocative—the NHS is still not driven often enough by the primacy of patient care. It is not, therefore, enough to say that the primacy of patient care will not be compromised by structural or financial reorganisations. We should surely be much more positively committed to the need to redesign services around patients, and I thought that that was one of the major purposes of the Bill. It is difficult to believe that in a modern world we can be content that people should stay in accident and emergency departments for four hours and longer. That is a question not just of resources but the way in which we design the service and the primacy we give to the patient. We cannot be comfortable that that is happening enough. I agree that we should not have more structural reorganisation, but that in itself is not enough. We should positively redesign our services.

The second reason why it is difficult to agree with this particular amendment is that if we are going to have a clear statement of values and principles, they should be clearly directed at the commissioning agent itself—the service—not to contractual providers. They should be built into contracts and specifications, and the service should ensure that these are taken seriously. I am afraid that the amendment seems to be muddled in that respect, and we cannot expect people performing functions to behave in a way that the commissioning agent is not specifying and requiring. Therefore, the values should be directed primarily at the commissioning agent.

I regret that I cannot support the amendment; I would like to see a clear statement of values early in the Bill, but this is not it.

--- Later in debate ---

[Lord Turnberg]

In speaking to these amendments, I am conscious that we are hamstrung by the fact that we have an education and training regulation or Bill to follow. So there is much to come. However, education is so important and so much an integral part of every aspect of the NHS that we must have some recognition of that in this Bill. It is just not possible to imagine a health service run by an uneducated workforce. I am obviously in support of all these amendments, and I am delighted that the Government have got their own helpful amendment in there, but there is much that remains to be clarified. I hope that noble Lords will forgive me if I go over some of these just a little. I should state my own interests of having spent most of my working life deeply involved in undergraduate and postgraduate medical education.

It is vitally important for the Secretary of State to take on responsibility for education and training in the NHS. It is how that responsibility is fulfilled that I want to focus on, by examining where the potential risks lie in this Bill to the system that we currently have in place and, indeed, where we might take advantage of the Bill to look for improvements in the way that we operate now. I will concentrate on medical education as the system I know best.

At the moment, GPs and hospital specialists are trained using a range of curriculums designed and delivered by the medical royal colleges. The colleges assess the trainees and set their exams, and all of this has to be approved by the General Medical Council. The GMC is the competent body set up under EU law that has to ensure that the training programmes reach the minimum standards set by the EU. It has to be said that in the UK we are way above those minimum standards. All of that is relatively straight-forward. But most of the actual delivery of all this training has to take place locally, at GP practices and hospitals. It is here that we have to be very careful as the NHS moves into its new mode of working.

At this level, the royal colleges have oversight of training through their own regional adviser network, while the postgraduate deans and their teams make sure that the conditions for training are right and that the trainees go through the programmes supervised by local programme directors. They are available in every major discipline and speciality. So there is a complex network for direct oversight of postgraduate education which currently works reasonably well.

However, it is the deans who carry the heavy responsibility of the budget for salaries for all of the trainees. They pay their salaries and they can, theoretically, withdraw funding for trainees if trusts fail to provide the right conditions for training. So the postgraduate deans are absolutely critical and yet their role is threatened as the strategic health authorities which now employ them seem to be disappearing. The deans have enormous power, and budgetary responsibility, but where will they go, and who will appoint and employ them now? I believe that it makes a lot of sense to think about them being employed somehow by the proposed new Health Education England when that is set up, but meanwhile it will be critically important not to lose them. Uncertainty about their future is not a good recipe for them to function effectively. They need some certainty now.

Leaving the deans aside for the moment, it is clear that the current system is dependent on close-working collaboration between them and the royal colleges, the GMC and, at the local level, the consultants and GPs doing the training. All this is going on in an NHS busily providing services for patients at the same time. This is the second threat to education, because it is increasingly evident that the service pressures on consultants and GPs are limiting their capacity to provide the teaching. They are increasingly feeling that the time available to teach is being eroded as service pressures build up. This is not a new phenomenon, but one that is more obvious now. The fear is that this will get worse unless—this is the key—we place a duty on the commissioners of the service for them to fund the extra sessions that consultants need to teach their trainees. One alternative might be for the postgraduate deans to have a budget for these sessions, but I suspect that this would not meet with much favour. I personally am not moved by it. It is a responsibility that we have to place on the commissioners.

Finally, I want to mention the public health doctors and their training in the brave new world. They are in some disarray, as I understand it from the public health doctors themselves. The directors of public health are to be transferred to the employment of local authorities. That makes some sense, at least on the face of it. But there may well be difficulties. They may find that the local authority terms and conditions are significantly different from the NHS terms. That may affect recruitment and retention. I have a fear of a return to the days of the medical officer of health, who was in the local authority, rather a rather sad figure remote from the medical community at large. However, rather more important is the training and education of public health doctors. It is quite unclear where the local authorities sit in relation to meeting the needs of those trainees in what is a vital medical discipline. It may be that all of this has been thought through. If so, it would be helpful to hear about it. The public health community certainly needs to know.

Meanwhile, I think that a better solution all round would be for the public health doctors to be employed by Public Health England and for them to be seconded to the local authorities. That might be more satisfactory all round, and it would give some security to the education and training of this key professional group.

I have not spoken about nursing education, not because it is not important—it clearly is—but because we are coming to it later in the Bill, and at least some aspects of nurse training and education will come in later clauses. I am sure that we will return to that. For the moment, I want to support this group of amendments, including that of the Government. But it seems entirely possible, I fear, that there will be further amendments at a later stage to try to tease out some of the issues I have been discussing.

[Lord Ribeiro]

My Lords, I thank the noble Lords, Lord Walton of Detchant and Lord Patel, for introducing this amendment. It highlights not only the importance of education and training in advance of the report that we will receive later in the autumn from the Future Forum group, but the fact that the Government have responded with an amendment of their own. That identifies the importance of bringing it on to the face of the Bill, so much so that it is right at the very beginning of Part 1. It is one of six duties that the Secretary of State now has to perform. That is very important.

It is quite understandable in a Chamber such as this one, full of doctors, that we tend to overemphasise the importance of medical education. As the noble Lord, Lord Turnberg, rightly said, nursing will be discussed later. However, it is not just about nursing. My wife is a physiotherapist—there are physiotherapists, radiographers and other healthcare workers as well. That is why the Government’s amendment talks about education and training without qualifying exactly which areas we are discussing. It is important that we bear that in mind.

The noble Baroness, Lady Finlay, I think, referred earlier to the independent sector treatment centres and the lack of training in that area. I must declare an interest as a past president of the Royal College of Surgeons. I had countless negotiations with the Department of Health to put into place a requirement for independent sector treatment centres to be able to train. The big issue was that all the surgeons and the ISTCs were overseas doctors. No UK doctors were allowed to train. We asked for a way in which we could introduce NHS consultants into what was effectively spare elective capacity. I fundamentally believe that we must separate emergency and elective surgery to produce the best-quality care for patients.

As a consultant, I would regularly do an out-patients’ clinic at Basildon hospital on Mondays. If I was also on call, as I sometimes was, I could be told that there was a patient in the emergency department who needed urgent treatment. That would ruin my out-patients’ clinic because I would have to go to theatre and sort out that patient. Our last assessment showed that 64 per cent of the general surgeons in Great Britain and Ireland have a responsibility to be on call while they are doing elective work. If you have that degree of commitment to doing two things, you cannot provide the best possible care for your patients. If NHS consultants could structure their work so that it was possible to work in a centre which was perhaps in the hospital—there are a few hospitals, including one in Nottingham, with elective centres within the hospital—or perhaps outside, they would be able to take their registrar and SHO to the independent sector and they would be able learn how to carry out the surgery.

[Baroness Finlay of Llandaff]

Perhaps I may ask for clarification from the noble Lord. I am not sure whether he is advocating that the duty in the government amendment should or should not be on every provider, whichever sector it is in. I tried to make it clear that I felt that the duty to provide education should be on everyone who provides patient services. I was hoping that the Minister would clarify that that was what was in the Government’s mind, so that history—what had happened before—could not be replicated.

[Lord Ribeiro]

I accept that point, although it might be difficult to implement when you consider the third sector and the voluntary sector, which may not be in a position to undertake education and training. That is a point to bear in mind.

[Baroness Finlay of Llandaff]

Forgive me but, as someone who works hugely in the voluntary sector and is a patron of many of the healthcare providers, perhaps I may point out that they carry out a great deal of education. An example is Marie Curie running NVQ courses for care assistants across the whole country. They are trying to drive up the standard of care given by people who are absolutely not at the medical end but whose care is critical to the quality of service that patients receive.

[Lord Ribeiro]

The noble Baroness makes her case but there is a wide spectrum of medical provision, and the question is whether this could be applied to every single provider. I am not clear about that but perhaps the Minister will be able to address it.

Returning to the question of training, I believe that through the Bill there is an opportunity, perhaps when the contracts for some of the independent sector treatment centres are up for renewal, to give some serious thought to whether these centres could provide the extra capacity that the NHS desperately needs if it is to go forward with the functional separation of emergency and elective care. I am of course talking about surgery and I recognise that that is a special case. None the less, we come from a history of one type of surgical provision to the situation in this Bill. If we are talking about quality as the indicator of the outcomes that we are looking for, it may well be possible to achieve this by utilising the ISTCs for NHS consultants. I shall give way if the noble Lord wishes to speak.

[Lord Winston]

I had no intention of interrupting the noble Lord. I merely thought that he was concluding his remarks and I was going to follow.

[Lord Ribeiro]

I take the distinct hint that it is time to conclude my remarks. I merely wish to say that we have an amendment in the Government’s name. It may well have been prompted by noble Lords introducing their own amendment, but the fact is that it is now there in the Bill.

[Lord Winston]

My Lords, I was interested to hear that the noble Lord, Lord Ribeiro, thought that the Chamber was full of doctors. I suspect that if we were discussing a legal matter, it would be full of lawyers, or if it was a matter relating to the City, it would be full of industrialists and so on. It depends on the nature of the Bill. It is very good that the Chamber is currently full of doctors because, like the noble Lord, Lord Ribeiro, we can give special credibility to the discussions and amendments that we are trying to tease out. It is a pity that there are not more members of the nursing profession in the Chamber, as well as others who are involved with healthcare and its wider applications.

--- Later in debate ---

I could go on but I will not. I just want to deal with what is becoming an urban myth about private providers of elective surgery services and their attitude to training. For my sins—it is a good confessional evening for me—I was responsible for negotiating wave 2 of the ISTC programme with the private sector. The private sector wanted more training responsibilities. It had been cut out of training in wave 1—a mistake—and it wanted training because it thought it would get better doctors working in its centres if they had a training function. Doctors in those centres wanted to see doctors in training, watching them and learning their trade in that setting, because those centres would be doing a very high volume of elective surgery, so you needed to use that. It has been put about in some rather strange way that the private sector did not want to do that. Frankly, it was not even in its commercial interests not to do that, so it is becoming a bit of an urban myth that it was trying to duck its responsibilities in the area of training.

[Lord Ribeiro]

I should just like to acknowledge that the references that I made earlier were to wave 1. I fully recognise and appreciate the work done by the noble Lord, Lord Warner, in trying to get a training contract with the private sector. However, there was a determination on the part of the Government when ISTCs were first introduced to keep the NHS consultants and trainees out of those centres.

[Lord Warner]

I ought to make clear that I was not launching an attack on the noble Lord, Lord Ribeiro, with whom I had an excellent relationship as a Minister when he was president of the Royal College of Surgeons.

I finish by saying that although we are making progress on this Bill by having amendments of this kind early on, it is important to realise their limitations. A number of noble Lords, particularly my noble friend Lord Turnberg, have raised a whole raft of issues which still need to be grappled with. This may be the first of a number of debates we have on the issue of education and training as we try to strengthen the Bill in this area.

Health and Social Care Bill

Lord Ribeiro Excerpts

Tuesday 11th October 2011 Lords Chamber

[Lord Ribeiro]

My Lords, I am pleased to follow the noble Lord, Lord Mawson, with his robust defence of entrepreneurship and innovation. The Health and Social Care Bill presents a once-in-a-lifetime opportunity to deliver a patient-centred health service. The Bill builds on the reforms of the last Labour Administration, but in a much more comprehensive manner. As a surgical registrar at the Middlesex Hospital in 1972, ward rounds consisted of doctors, nurses, physiotherapists, social workers and the lady almoner. Coffee in the sister’s office provided an opportunity to plan the progress of patients from hospital to home care and support in the community. This was an example of hospital care working closely with social care. Subsequent reviews and reforms of the NHS have entrenched the separation between social care and health care, and this Bill addresses a need for an integrated service led by clinicians who should have a greater say in how the service is commissioned and delivered, but must also be prepared to accept the responsibility and accountability that this autonomy provides.

For too long, political interference in the day-to-day management of the NHS, occasioned by the need for politicians to account for taxpayers’ money, has bedevilled the NHS. Micromanagement and top-down diktats imposing targets and guidance, often with no sound clinical evidence to support them, have frustrated clinicians over the years, stifling leadership and innovation. I should know, because I have often been at the receiving end. The emphasis placed on quality outcome measures by the noble Lord, Lord Darzi, as he eloquently outlined today, and in his NHS review of 2008, indicated for the first time a move from politically driven targets which were process-based to evidence-based practice supported by research.

The Government’s White Paper Equity and Excellence: Liberating the NHS was widely welcomed in July of this year by the profession. It noted that:

“The primary purpose of the NHS is to improve the outcomes of healthcare for all”.

It went on to say:

“Building on Lord Darzi’s work, the Government will now establish improvements in quality and healthcare outcomes as the primary purpose of all NHS-funded care”.

Clause 2 does just that. It talks about outcomes, the effectiveness of the services, measured by clinical outcomes and patient-reported outcome—something which is already happening within surgery, the safety of the services and the quality of the experience undergone by the patient. The inclusion of research as a new duty for the Secretary of State puts an onus on him or her to promote the use of evidence obtained from research, a duty which also relates to the NHS Commissioning Board and the clinical commissioning groups. Other noble Lords will, I am sure, speak about the importance of research, but it is important that the Chief Medical Officer who, as the Chief Scientific Adviser and Director of the National Institute of Healthcare Research, must be given the independence of action to ensure that the Commissioning Board and the clinical commissioning groups take account of the evidence of research.

In a debate on the NHS Futures Forum on 15 September, I raised the issue of the independence of the Commissioning Board and the need to free it of political interference. I referred to the King’s Fund report Reconfiguring Hospital Services as an example of how hospital services can be reconfigured without political interference, making reference to the experience in Ontario. The decision to close the A&E and maternity services at Chase Farm was an example of how the evidence for reconfiguration has been available for many years—17, I believe—but the political will to use it was lacking. Freed from such pressure, the Commissioning Board should be able to make decisions which politicians find difficult to make, even when the evidence for change is there for all to see.

The White Paper also called for clinical leadership and this was echoed by the Future Forum. Now is the time for the medical profession to stand up and be counted. The Royal College of Surgeons, of which I am a Fellow and a patron, has said very firmly that the time for delay has passed. It is nine months since the Bill was first read; an in-depth review by the Future Form, taking evidence from more than 7,000 people and receiving 25,000 e-mail comments, has been accepted almost entirely by the Government and many amendments reflecting their concerns are now included in the Bill.

As a surgeon, I am aware that we must do more to deal with the demand for healthcare. Much of this relates to public health. The problems relate to obesity. Britain has among the worst levels of obesity in the world and it is increasing. Smoking claims over 80,000 lives a year, and alcohol dependency is a problem for 1.6 million people in the UK. These are all public health issues which put enormous strain on the capacity of the NHS to cope. Diabetes, cardiovascular disease, respiratory diseases and cancer are some of the non-communicable diseases which are on the increase and they require prevention rather than cure.

Public health, in the form of clean air, clean water and sanitation and vaccination against communicable diseases, improved the health of the nation during the last century. It has increased the quality and the extent of life. We need to make provision for our elderly population, through greater integration of our health services, dealing with social care as well as acute care, and focusing on a care pathway, not just the condition. The Secretary of State’s responsibility for public health is welcome and is a clear indication that the Cinderella service has come of age and can take its place alongside acute care in terms of the total care of the patient.

Like many noble Lords, I have received countless e-mails about today’s debate. An abiding theme is privatisation and the Americanisation of our health service and the threat of cherry-picking by American companies. It might be helpful to put the term “cherry-picking” in context. It was first used in a submission I made as president of the Royal College of Surgeons to the Health Select Committee of the House of Commons when we were meeting on the independent sector treatment centres in February 2006. On 10 January 2006, the Secretary of State said of the independent sector:

“But I recognise that other reasons for using the independent sector to add to the innovations already happening within the NHS and to introduce an element of competition and challenge to under-performing services is a harder argument to win, so we will continue to respond to legitimate concerns, for instance to ensure that training for junior doctors is provided within the independent sector treatment centres”—

that still has not happened—

“and more generally to provide a level playing field for different providers within the NHS”.

That was five years ago. In my oral submission to the Health Select Committee on 9 March 2006, I welcomed the Secretary of State’s statement as it sought a level playing field. “Any qualified provider”—with the emphasis on “qualified”, as the noble Baroness, Lady Jay, required—seeks to ensure that competition within the NHS will be fair. It is not a new concept and I believe that the Bill addresses the concerns raised in 2006. In Committee, I will seek to explore in more detail how post-operative complications arising from surgery by qualified providers will be managed, to ensure that they do not place an unfair burden on the NHS. For many years, the medical profession has called for an end to top-down management, targets and political diktats on health, and they remain frustrated with the workings of the PCTs.

This Bill heralds a shift from central command and control to patient and professional power. It provides an opportunity to improve health outcomes for patients and remove layers of bureaucracy which have built up, at great cost to the NHS. No change is not an option. Doing nothing will see health costs rise to £130 billion by 2015. We need to act now to safeguard the NHS for future generations.

NHS Future Forum

Lord Ribeiro Excerpts

Thursday 15th September 2011 Lords Chamber

[Lord Ribeiro]

My Lords, I thank the noble Baroness, Lady Wheeler, for introducing the debate. The Future Forum addressed four core themes, many of which she has covered: choice and competition, patient involvement and public accountability, clinical advice and leadership, and education and training. The latter, as she correctly described, is still work in process under Julie Moore, who led the forum’s work on education and training. The Government have accepted that deaneries will oversee the training of junior doctors and dentists, and that that will be under the umbrella of Health Education England. That should give some reassurance to the profession, but it remains unclear who should be responsible for quality assurance of training. I do not believe that a “one size fits all” approach works, particularly with respect to the craft specialties. In this, I include surgery—here I must declare an interest as a past president of the Royal College of Surgeons. Prior to the introduction of the postgraduate medical education and training board, known as PMETB, currently responsible for quality assurance, colleges had the responsibility for accrediting training. I believe that the craft colleges are ideally placed to undertake the quality assurance of training, ensuring professional clinical input under the auspices of Health Education England.

Turning to clinical advice and leadership, the forum called for multiprofessional involvement and leadership at all levels of the system. The NHS commissioning board is a good place to start. I welcome the Government’s statement that the NHSCB will establish close links with the royal colleges and other professional bodies to entrench partnership-working at the national level. The board will have a medical director and a chief nursing officer—rather reminiscent of the old days of matron, senior medical officer and administrator, who used to run hospitals before the 1974 reforms. The board needs to be independent and free of political interference.

The role of the Secretary of State has been clarified in the Bill. I know, after following the debates in the other House and the views expressed by the noble Baroness, Lady Wheeler, that there is still concern about the role, but I believe that it is clearly expressed in the newly amended Bill. The Secretary of State will have a mandate to provide clear direction to the board, and the board will then be accountable to the Secretary of State.

One of the biggest problems that any Secretary of State faces is the reconfiguration of services—in particular, hospital services. The King's Fund this month produced a report, Reconfiguring Hospital Services. The report highlights the urgent need for clinical reconfiguration of hospital services in some locations to improve the quality and safety of patient care. The ability of politicians to interfere with the process of reconfiguration is well known, and the sight of MPs of all political persuasions on the picket line outside hospitals threatened with closure is not uncommon. The evidence presented by Chris Ham of the King's Fund of the Ontario experience in Canada suggests that an independent body can make hard decisions. The health service’s restructuring commission set up in Ontario in 1996 to restructure hospital services not only achieved its mandate but saved $1.1 billion in a total spend of $17 billion. This amount was then reinvested in other services.

The commission drove the establishment of clinical networks, a recommendation made by the Future Forum, and invested in home care and long-term care to facilitate hospital closures where required. Chris Ham also noted that the process used was not dissimilar to that used in this country to support the closure of mental and learning disability hospitals in the 1990s. The Government then transferred funding ahead of hospital closure to develop community services.

We must learn from these lessons. The Secretary of State should not be concerned with operational matters, but should be focused on strategy. Liberating the NHS implies liberating the service to rely more on professional clinical leaders. Armed with evidence, backed by research—another new responsibility for the Secretary of State—evidence-based practice can be used to reform the health service.

I believe that delay is not an option. The impact of specialisation, and in particular the European working time directive, of which we have heard much in this House over the past few years, will make it impossible to provide emergency surgical cover in all hospitals with accident and emergency departments in England. The development of trauma centres in London will create a new paradigm shift in acute care management. Reconfiguration of emergency services will be an inevitable consequence of this change, which will ultimately affect all hospitals in England. The Darzi principles, mentioned by the noble Baroness, Lady Wheeler, are important. They introduced quality outcomes based on the effectiveness and safety of the services delivered, and the quality of the patients’ experience remains a fundamental principle on which, I believe, the Health and Social Care Bill can build.

Smoking

Lord Ribeiro Excerpts

Thursday 8th September 2011 Lords Chamber

Asked by

[Lord Ribeiro]

To ask Her Majesty’s Government whether they will introduce legislation to stop adults smoking in cars when children are present.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, exposure to second-hand smoke is hazardous, especially to children’s health. Since smoke-free legislation was introduced in England in 2007, evidence shows that the number of children being exposed to second-hand smoke has continued to fall. However, some children are still exposed in the home and in family cars. We want to encourage people to create family environments free from second-hand smoke. The Government are proposing a range of voluntary measures that we believe can achieve more, more quickly, than legislation.

[Lord Ribeiro]

My Lords, I thank the Minister for his considered response. The evidence of damage to children from passive smoking is well documented. Thirty jurisdictions in Canada, Australia and the United States have banned smoking in cars when children are present. In Canada, exposure to smoking in cars fell by one-third to one-half in some provinces over a six-year period. Is my noble friend aware that the concentration of smoke in the back of a car is considerably greater than that in the front, even if the driver’s window is open? Is he prepared to follow the example of the Welsh Assembly and introduce legislation if efforts to change behaviour fail?

[Earl Howe]

My noble friend speaks with great authority on this subject, and I find little to disagree with in anything that he has said. He is absolutely right that children are particularly vulnerable to the harms of second-hand smoke: more than 300,000 children in the UK present passive smoking-related illnesses to their GP every year. We have to take this matter seriously, and we are. However, despite the evidence my noble friend cites from Canada, it is still early days to judge how effective that legislation has been, over and above voluntary measures. The second issue that poses problems is enforcement. However, we continue to look at these questions very closely.

NHS: Clinical Excellence Awards

Lord Ribeiro Excerpts

Monday 27th June 2011 Lords Chamber

[Earl Howe]

My Lords, in building the NHS that we all want for the future, we need to continue to recognise and reward those individuals who give outstanding patient care and who contribute in a notable way to clinical academic excellence. At the same time, we need to ensure that the system in place to do that is effective, affordable and in line with other public sector reform. It is those questions that the Doctors’ and Dentists’ Review Body is considering at the moment.

[Lord Ribeiro]

Does the Minister agree with the Academy of Medical Royal Colleges, the Academy of Medical Sciences and others that clinical excellence awards make an important contribution to the quality and excellence of care in the National Health Service? How will the replacement of these awards by one-off non-pensionable awards, like the proposed surgeon of the year prize, improve standards?

[Earl Howe]

My Lords, as I have just said, we believe that financial rewards, in the form of clinical excellence awards, should remain. It is just a question of how that system is designed. We have not said that non-financial recognition should take the place of financial awards. They would operate alongside financial awards; they would not in any way supplant them. However, we think that there is a role for perhaps more imaginative thinking in areas like speciality-based awards or departmental or division-based awards, for example, or indeed ad hoc recognition for outstanding clinical leadership. The DDRB is looking at these questions too.

NHS: Consultation on Reform

Lord Ribeiro Excerpts

Tuesday 26th April 2011 Lords Chamber

[Earl Howe]

My Lords, I am aware of that concern. This matter has occupied the minds of Ministers. I say to those who are serving in the NHS day by day and, indeed, to the pathfinder consortia and the early implementer local authorities that they should continue with the work that they are doing because it is from them that we most wish to hear about the practical lessons that our proposals may point to. It is, I am sure, an unsettling time for them but we hope that after this period of reflection we can continue with the passage of the Bill with proper momentum.

[Lord Ribeiro]

Does the Minister agree with me that the principles referred to earlier underpin the NHS reforms? These principles are supported by the coalition Government and follow on from the same reforms that were introduced by the previous Government. I would like him to acknowledge that these principles should be reaffirmed in any response to the listening exercise.

[Earl Howe]

My noble friend is quite right: the principles that underpin the Bill and—I emphasise this—the principles that have always underpinned the National Health Service, are not going to change. He is right that the approach that we are adopting is in many senses an evolutionary one, following on from initiatives taken by the previous Government. I am grateful to him for pointing that out and I am sure that this will be a feature of the government response that we shall publish in due course.

NHS Reform

Lord Ribeiro Excerpts

Monday 4th April 2011 Lords Chamber

[Lord Ribeiro]

My Lords, I thank my noble friend for repeating the Statement. The health reforms are necessary because they address the complexity and cost of medical care, which are growing daily as our population also grows. Our elderly population is growing simply because of the improvements in healthcare over the past few years. Here I acknowledge the unprecedented funding provided by the previous Government to stimulate the health service in its development. This Government have agreed to enhance that funding.

The noble Lord, Lord Darzi, signalled a change from process management to service delivery based on quality. This Government have accepted the challenge to pursue a quality agenda, knowing that, although quality care is costly, at the end of the day—particularly in my speciality, surgery—there is no question that good quality care, particularly the use of minimally invasive surgery, leads to early discharges of patients and better outcomes. I hope that this principle of quality is something that the Government will pursue. Is it my noble friend’s intention that the emphasis in health reforms should remain on quality outcomes being the bedrock of the reforms?

[Earl Howe]

I can reassure my noble friend Lord Ribeiro instantly on that. He will know, I am sure, that the acronym that was coined by the previous Government, QIPP, which stands for “quality, innovation, prevention and productivity”, is symbolic of a whole series of workstreams not just in the Department of Health but throughout the health service to ensure that quality is maintained and enhanced in the service. Unless we deliver higher quality to patients, the service will not be sustainable. Some people say that higher quality care costs more money but, as my noble friend will know from his own craft speciality, the better the care that you deliver the less costly it often is because care that is delivered in a substandard way often results in unintended consequences, such as patients returning to hospital with complications. We need to drive safe care and right care in the system.

Many of the levers that we have to improve quality are not in the Health and Social Care Bill at all—for example, the need to roll out the information agenda, without which there can be little transparency of quality. Those activities are being pursued with energy and drive in my department.