Health and Social Care Bill

Lord Turnberg Excerpts

Monday 27th February 2012 Lords Chamber

[Baroness Hollins]

My Lords, I support the amendment, particularly because it draws attention to the point that often patients experience prolonged psychological harm after an incident, something that is not well understood across the whole of the medical field. Such psychological harm is often overlooked. However, there is plenty of evidence that an honest and prompt apology can do so much to help the person and their family going forward. It is fair to say that delaying a response is very much like denying a response. The timeliness of a response is critical.

[Lord Turnberg]

My Lords, As someone who taught medical students for many years that it is very important to be absolutely open and candid with your patients, and that, if something has gone wrong, to explain it in full to the patients and their relatives—explaining that that is not necessarily an admission of guilt in some way—I am very keen on the sort of sentiment that is being expressed in this amendment. I am particularly keen on the GMC imposing on doctors the duty of being open. I am all behind the sentiments of this amendment. I have some anxiety, though, about how this can be put into law. How can you legislate for someone to be candid? How will it work? How do you know that someone has been candid or not? There is a great deal of subtlety about this candour and about putting it into law as a duty on every occasion. I am slightly apprehensive about the amendment, even though I support everything about the principle.

[Lord Winston]

My Lords, I find it very difficult, as I have said before, to accept or support this kind of amendment, but I strongly believe in candour and I totally support what many noble Lords, including my noble friend Lord Turnberg, have said around the House. However, there are major problems with putting this kind of amendment into legislation, which would make it extremely difficult to be reasonable. There would be real risks of serious psychological harm to quite a lot of patients. One of the last things we want to do is to involve patients in a perceived injustice or perceived negligence which turns out to fail miserably in the courts of law. I have seen that as horribly damaging with patients I had in the past when I was a medical practitioner, which I am of course no longer.

The other issue not adequately dealt with in this amendment is that of time. At what stage is it justified no longer to be candid? Should somebody who, let us say, sees something from that same health authority a year or two later, or three or four, still be candid about what they think may have gone wrong, or where they are not absolutely certain that it has gone wrong? There is a colossal difficulty in trying to enforce this. Far better is the idea of having some kind of code of practice, to which I think my noble friend Lord Turnberg referred, which ought to be acceptable to doctors.

When I was a trainee surgeon, we did innumerable partial gastrectomies. We now know that that operation was really mutilating and totally wrong; it actually resulted in many people losing weight and not being able to hold down a proper diet. Subsequently, of course, peptic ulceration could be treated by a simple antibiotic therapy. Now, at what stage does that treatment become established or a gastrectomy become a negligent operation? These are very difficult things to define, and I urge that we should not write this proposal into law in the way that is proposed.

--- Later in debate ---

[Lord Sutherland of Houndwood]

My Lords, I support the amendment for three reasons. First, were it to be implemented, the effectiveness of the care provided would be magnified and significantly improved for every individual involved. Secondly, there would be better value for money. Whether we like it or not, the two professions fight with each other over budget: that is the reality. Unless they are pushed towards talking to each other seriously—which this amendment does—that will continue, and we will have the consequence of expensive hospital care militating against the provision of adequate home care. Thirdly, human beings are individuals. Over time especially, they have a number of ailments that need to be seen together, and they need to be treated as individuals. An individual does not break up into bits, going to one institution for part of his or her care and to a second institution for another part. There is a real difficulty here. Previous research shows very clearly that trying to put a dividing line between health and social care does not work.

We hear statements implying that it is going to be really quite difficult. This is not rocket science. It must be based on two professions coming together. This is being done in Scotland at the moment, and they have found ways to move ahead. I understand that there are pilots going on in England at the moment sponsored by the department, and I look forward with great interest to seeing what comes out of these. However, there is a lacuna in the Bill regarding how health and social care integrate. As long as this is so, the amendment would push things forward significantly.

[Lord Turnberg]

My Lords, we have heard that integrated care means different things to different people. As far these amendments are concerned—including the one to which my name is attached—the focus is on the integration of hospital care, NHS care and social care. Almost since its inception, the biggest problem for the NHS has been the division between health and social services; the division between funding—which of course drives everything—and management.

Acute services have always been the focus of most NHS funding. One might expect me to say, as a former acute care physician, that that is entirely appropriate. However, it has always been clear that this division, with different funding streams, has led to dreadful miscommunication between two sets of staff working under quite different systems, who fail to talk to each other in anything like a timely manner.

The end result is well rehearsed. Patients who would have been much better cared for at home—or in a nursing home if one were available and if someone could have made a proper assessment—finish up in an acute hospital which is poorly designed to provide the sort of care that they really need. On the other side, patients—usually elderly—are admitted to hospital for entirely appropriate reasons, but linger there well after their acute need has been sorted out. Clearly, if we had common funding of health and social services, we could see people employed across this divide. That is what we need: people with a foot in both camps. I take the point made by the noble Lord, Lord Mawhinney, that it takes two to tango—it takes both the heath service and local authorities, and they do not tango terribly well. While we do not have common funding, however, at least we can work towards it. Here we have an opportunity to emphasise the duty that should be placed on the NHS, for one, to ensure integration at this level. This is of such importance for patients that we should emphasise it at the least in this relatively minor way here.

[Lord Newton of Braintree]

My Lords, I support—with some trepidation—what my noble friend Lord Mawhinney has said, and I pick up the point about it taking two to tango. I yield to nobody in my support for integrated services. I heard what the noble Baroness, Lady Young—a person with whom I go back a long way—said about diabetes, and I do not disagree with it. I do not disagree with what the noble Baroness, Lady Pitkeathley—with whom I go back even further I think—said, presumably arising from her experience as part of Age Concern. The question is whether this amendment does it, or whether in fact it contains things which will make it more difficult. As the noble Lord, Lord Turnberg, said, it takes two to tango. As I read it, every responsibility here is laid on health service bodies, not local authority or social service bodies. If we are to go down this sort of path, we need to lay equal obligations on both.

However, the issue goes beyond that. It should be recognised that one of the most difficult or most needy areas in this field is mental health, which I know something about even though I no longer have a direct interest. With mental health there is a need for co-operation not just between the various statutory authorities—indeed, many mental health trusts are partnership trusts with the local social services department and have made significant progress, as was true of the one with which I was involved until January—but with voluntary organisations. Where are they covered in all this? I had a difficult case in a mental health trust that I chaired 10 or 15 years ago. Nobody in any statutory service, whether local authority or health, had known that the patient in question was undergoing anger management courses paid for privately, and that caused problems. Last weekend, I was talking to someone in Braintree who is interested in the Rethink Mental Illness charity and is trying to build up the local Rethink art therapy classes, for which he thinks he has acquired a building. That, too, ought to be integrated with the services provided by the mainstream.

I do not believe that this amendment, however valuable it is and however worthy its objective, will achieve that objective without a great deal more sophistication. Personally I would rather leave it to the Minister and his department to issue guidance and apply pressure in rather different ways to produce the integration that we all want. At any rate, I look forward to what the Minister has to say. He may draw more encouragement than usual from some of my remarks and I might even vote with him if it comes to that.