Health and Social Care Bill

Lord Walton of Detchant Excerpts

Tuesday 11th October 2011 Lords Chamber

[Lord Walton of Detchant]

My Lords, as it is 66 years since I graduated in medicine, I can say with total confidence that I am the only Member of your Lordships’ House who was practising medicine before the NHS came in. I can remember, as a paediatric houseman in 1945-46, seeing children admitted with perforated appendices because two penn’orth of castor oil was cheaper than the doctor. Thank goodness that after the health service came in—and I am one of its most fervent supporters—that kind of experience became something of the past.

In 1996 I was invited by the British Medical Association to give a lecture to celebrate the 50th anniversary of the passage of the NHS Act, which I was very pleased to do. I said that in those 50 years I had lived through eight reorganisations of the NHS. In the 15 years since I gave that lecture there have been nine major and minor reorganisations. No Government have ever been willing to let the people in the NHS get on with it without producing some kind of modification.

Looking back over those years, I recall that in 1974 I was dean of a medical school when Lord Joseph, as he became—he was then Sir Keith Joseph—as Secretary of State, introduced a massive reorganisation of the NHS. It was a painful experience. It was based totally on a detailed report by McKinsey management consultants that the Government at the time swallowed whole, and they created district health authorities, area health authorities and regional health authorities. The reorganisation introduced consensus management and the result was that the whole decision-making process in the NHS congealed. The reorganisation took two years to implement. It took another two years to show that it was disastrous, and another three years to get rid of it. I just want to be quite clear about the reasons why I look upon this Bill, enshrined in two enormous volumes and 300 pages, with a certain healthy scepticism—as I have done over a number of other reorganisations. Do any of your Lordships remember, much more recently, the primary care-led NHS? That was an arrangement that foundered without trace.

The Bill in its original form was, in my opinion, potentially dangerous and totally unacceptable. I have to say that the Future Forum under the leadership of Steve Field has produced significant improvements, but the Bill remains full of potential hazards. I know that my noble friend Lord Owen has done his best to produce an amendment that he believes would allow the possibility of making the Bill much more acceptable. I have reservations. I have not yet decided which way I shall vote, although one reason for not voting for his amendment is that I am now in my 90th year, and the delay that it would cause might make it uncertain that I would be able to contribute to the later stages. However, that is another issue that we will look at in a moment. I am going to confine myself and not talk now about the responsibilities of the Secretary of State or about competition. I am going to keep my powder dry on such issues until Committee.

Today I want to mention four things that give me particular concern. The first is commissioning. I believe that there has been a vast improvement in the standard of general practice in the UK since the introduction years ago of vocational training. I have an excellent general practitioner—he was one of my former students—and I have discussed with him this issue. He is the very first to admit that whereas he and his GP colleagues can fulfil a major role through these new commissioning groups, they do not have the expertise or knowledge to be able to fulfil the responsibilities of commissioning highly specialised services. That will fall to the national Commissioning Board.

Recently I have served on two all-party group inquiries looking at facilities across the UK for patients with neuromuscular disease and for patients with Parkinsonism. They demonstrated a remarkable unevenness of standards of diagnostic services and of care in these specialties in different parts of the country. When these major deficiencies were drawn to the attention of the chief executives of the strategic health authorities they were so shocked that they took action to correct the problem.

I do not believe that the national Commissioning Board, as a single entity, could—however experienced, however distinguished—look after national commissioning across the entire country. It is inevitable, and I believe that David Nicholson agrees with this, that there must be not a regional—that is not an attractive word nowadays—but a sub-national component, with these individuals commissioning throughout the country, and they must be located, I hope, in relation to the so-called clinical senates which are going to be introduced. We are living in an era when genomic medicine is developing a whole series of new treatments and orphan drugs are emerging for patients with rare diseases. Some time ago it was unthought of that these diseases would be amenable to treatment. Therefore a sub-national commissioning responsibility is absolutely crucial to help to advise the national Commissioning Board on its responsibilities.

I turn now to education and training. There is nothing in the Bill at all about the crucial relationship with the universities for the undergraduate training of doctors, dentists and other healthcare professionals. That must come in. Equally, the Bill takes no real account of the fact that, ever since the NHS began, it is the statutory responsibility of the National Health Service to provide postgraduate training for doctors, nurses and dentists in specialties. That is the financial and organisational responsibility of the NHS.

There was an astonishing suggestion in the original White Paper that they were going to replace the postgraduate deans with local skills networks. This was utterly staggering and took no account of the fact that the postgraduate deans play a major role not only in appointing young doctors to their foundation posts and specialist registrar posts, but in providing the postgraduate training that is so essential for the future. Perhaps I may ask the Minister in what way these deans, with the abolition of strategic health authorities, will have the ability to make certain that foundation trusts and commissioning groups will provide the facilities that are essential for the education of these individuals. This must be in the Bill but it is not there at the moment. It is crucial that that is recognised.

Also—and I speak as a former president of the General Medical Council—under the Medical Acts the GMC has the statutory responsibility to oversee and provide high standards of medical education and to co-ordinate all phases of medical education in collaboration with the medical royal colleges and so on. The Bill is silent on that issue.

The noble Lord, Lord Willis, made an excellent speech, and so did the noble Baroness, Lady Warwick, about research. One must recognise that although there are three sentences in the Bill about the responsibility of the NHS for research, they are not enough. Today’s discovery in basic medical science brings tomorrow’s practical development in patient care. Years ago I chaired an inquiry into research in the NHS, which led to the Culyer report and led, eventually, to the establishment of the National Institute for Health Research. The Government of the day said that 1.5 per cent of the national health budget would be spent on research. It has never got up to more than 0.9 per cent, but nevertheless could the Minister confirm that the work being done by NIHR under the inspired leadership of Dr Sally Davies and others will be protected? Will it be made clear to commissioning groups and independent foundations trusts that they have a responsibility for research? I echo entirely what the noble Lord, Lord Willis, said about the crucial importance of accepting the report of the Academy of Medical Sciences, so expertly chaired by Sir Michael Rawlins, which will make the organisation of clinical trials, which have become so incredibly complex, very much easier. It is important that this be enshrined in the Bill.

There is so much more that I could say, but the Bill at the moment is shot full of deficiencies, ambiguities and other defects. It is incumbent on this House, with its expertise and the experience of its Members, to see this Bill through a long and detailed Committee stage to amend it and make it acceptable, in the interests of the long-suffering healthcare professionals and, above all, our patients and the British public.