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The noble Lord’s prescription is therefore to raise London’s game and—in a nutshell—to locate the right level of healthcare where it is needed. He is much better placed than I to describe to your Lordships what each level will look like: specialist and major acute hospitals handling more complex care; polyclinics for community-based services; local hospitals with a redefined role; and elective treatment centres. I have no doubt that he will wish to flesh out his vision for

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these different tiers of service. But the purpose of such a reconfiguration is not in dispute: it is to improve the quality of care delivered by the NHS across the board and to focus also on prevention and health promotion, which in many areas of the capital receive scant emphasis. Those aims are to be thoroughly applauded.

It is the implications of some of these proposals which the noble Lord will know have been exercising the healthcare community since his report was published. Perhaps their most obvious implication is that they would lead to radically new ways of working for many professionals, especially consultants. Staff, including GPs and nurses but also, particularly, the London Ambulance Service, will need to acquire different skills. These things would be necessary and far from insurmountable, subject to sorting out issues relating to the transfer of employment. But some of the other implications are perhaps more problematic.

There are several that have loomed large. The first is how we get from A to B. The road map to implementation is not yet clear. The creation of a double running fund to allow new facilities to be created while the old are still in operation poses considerable financial questions, and it would be helpful to hear from the noble Lord what the up-front investment is likely to be.

The second concern I have relates to the financial savings that are posited from the new arrangements. These are given as £1.5 billion a year, but again it is not self-evident to me how such large savings might arise, bearing in mind that the delivery of care by a polyclinic is unlikely to be less expensive than the delivery of care by GPs and a district general hospital. I worry too about the continuing viability of PFI hospitals which currently depend on revenue streams that would be removed from them under the proposed arrangements. If these hospitals are not to close—and the fear is that some might have to—has enough work been done to test alternative budgetary models?

No one can object to the idea of setting up a polyclinic in an area where family doctor services are weak and community access is difficult. But what is seen to be the benefit of shutting down hundreds of GP surgeries where primary care is being delivered to a good standard? Doing so may well involve longer distances for patients to travel in order to access primary care. And if the services provided in a particular district general hospital are viable, successful and accessible, is there really a compelling case for shipping those services out to a different location?

There are perhaps two areas of hospital care where special concern arises. The first of those is maternity services. The noble Lord has rightly focused on maximising choice for expectant mothers, but he has also worked on the assumption of a smaller number of obstetric units with a relatively high level of consultant presence on each of them, and at the same time a larger number of midwife-led units than at present. The difficulty here is the lack of an evidence base in relation to patient safety. Quite frequently, women who are about to give birth in a midwifery unit need to be transferred to the care of an obstetrician. Exactly what is a safe distance between a midwife-led unit and a consultant-led unit? How are

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we to decide—and indeed who will decide—on the location and staffing levels of both types of unit, and on what research data will they base those decisions? The background here is not only a shortage of midwives in London but also a rising birth rate, and it will clearly be essential to have a configuration of services that is reasonably future-proof.

The second main area of concern is accident and emergency. Under the noble Lord’s proposals there would be more urgent care centres but fewer full A&E departments. The question, once again, is about the evidence base for this model. Although urgent care centres are likely to be called “A&E”, they will lack intensive care beds, and it is that which will govern outcomes in a significant number of cases. Of course, ambulance crews would be trained to take a patient to the hospital with the right level of care, but there are a number of medical emergencies—for example, where someone is having breathing difficulties—where the distance the patient has to travel has a direct bearing on that person’s chances of survival. The downgrading of district general hospitals from being able to provide full accident and emergency cover needs to be justified by the most rigorous research. It is interesting that the Academy of Medical Royal Colleges, if it has been reported correctly, maintains that most district general hospitals should be able to provide full A&E, even if in some specialties they lack critical mass in terms of patient numbers.

In raising these issues, I do not want the Minister to think that I am pouring cold water on ideas that are clearly the product of intensive consultation. I have the highest respect for him, and am more than ready to be convinced. However, it seems that work still needs to be done on some of the feasibility aspects. It would be helpful to know whether the recommendations in his report represent official government policy. If they are ultimately to succeed, it is essential that patient groups and healthcare professionals—not least the GPs—should feel a sense of ownership of the changes. To that end, there may well be a case for piloting the polyclinic model in one or two areas to demonstrate how it could be made to work.

I hope the Minister will take my questions in the constructive spirit in which they are meant and look I forward very much to hearing his reply.

7.35 pm

Lord Warner: My Lords, I welcome the noble Earl’s decision to have a debate on this important issue, and I congratulate him on the constructive way he has approached the subject today. It is important that we are able to have honest and open debates about this difficult set of challenges in a major urban complex.

I welcome the opportunity this gives me to congratulate my noble friend Lord Darzi both on his appointment as a Health Minister—we may end up commiserating with him at a later date, from my personal experience, but at this moment, in the flush of newness, I congratulate him—and on the report he has produced. I want to mention the inclusive way in which he went about producing it, bringing in a range

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of opinions. I observe also that he is going about the wider review that he is conducting in exactly the same way. Many will appreciate the inclusive way in which he is going about his work.

I have to declare an interest. For the past six months I have been the part-time chairman of a new body set up by the London Strategic Health Authority called the Provider Agency, operating from the SHA but in a more arm’s-length way on a day-to-day basis. It is concerned with the performance and development of those acute and mental health trusts that are not yet foundation trusts and helping them to achieve FT status. We have recently taken on a similar development in relation to PCT provider services, and are currently engaged with tackling the problems of the eight “financially challenged”—as they are euphemistically called—acute trusts in London. Some of those problems are very longstanding and go back many years. In tackling them, we will be drawing on the valuable contribution made by my noble friend Lord Darzi in his framework report.

So I am right in the middle of the challenges faced by London’s NHS. Many of these issues not only go back in time but are also complex, often having at their heart a reluctance to tackle difficult clinical, organisational and—dare I say it?—political problems. The noble Earl will perhaps be relieved, or perhaps not, to know that I am going to behave in a non-partisan way today. I do not claim that this mood will last forever, but so far as today is concerned there is probably a large measure of agreement about the kinds of problems that have to be tackled in London. As the noble Earl said, a lot of it is about how we go about tackling those issues.

My noble friend made a major contribution with the document he published earlier in the year, setting out some of the causes that make it necessary for us to engage with change. I shall pick out just one of his eight reasons: the health inequality issues, which the noble Earl drew upon. We all know that if you travel down the Jubilee Line from Westminster to Canning Town, you will find at the end of that journey that the life expectancy at Canning Town is seven years less than that at Westminster. That is a major issue for London. One of the issues we have to grapple with now is how we transfer resources to the parts of London that are less well provided for from those that have strong resources.

I do not have much time left. I offer two thoughts. First, we have to tackle the weakness of community services in many of our deprived areas, and we need to bring in a richer mix of providers to do that. Secondly, we have to consider how we use land, buildings and equipment in London, which has some of the most expensive real estate in the country, and use those resources more efficiently and effectively to help deliver some of the vision in my noble friend’s report.

7.40 pm

Baroness Masham of Ilton: My Lords, I thank the noble Earl, Lord Howe, for giving us a chance to welcome the noble Lord, Lord Darzi of Denham, to

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your Lordships' House as Minister responsible for health. As a leading and dedicated professor of surgery, the Minister may find it difficult to comprehend the many challenges that face the NHS as there are so many different principles.

London, with its diverse communities, has become a huge challenge to the NHS. The scourge of drug and alcohol abuse and the increasing incidence of gunshot and stabbing injuries increase pressure on it. My heart goes out to the family of the Polish care worker who was killed in crossfire last week.

A priority in patient care should be the quick release of results of tests and scans, correct diagnosis and the most appropriate treatment. That would lessen the risk of long-term disability, as was illustrated to me on a visit to King’s College Hospital.

As president of the Spinal Injuries Association, I have seen many disasters occur when patients with injuries to the neck and back, which can lead to paralysis, are not treated in a specialist spinal unit. Accidents happen in so many different ways. A young electrician in Westminster who fell through a skylight landed on a spike which pierced his liver and severed his spinal cord. Once his liver was repaired, he was transferred to Stoke Mandeville Hospital for spinal treatment. The priorities are the treatment of bladder and bowels and the prevention of pressure sores. General hospitals in London lack the routines required and the trained staff.

On a visit to Lambeth Walk health centre, I found excellent fast-track testing for HIV, with the results available in a few hours, counselling if the results are positive and referrals to specialists. However, numbers of health visitors and community midwives have been cut, which is worrying in a deprived area.

So much could be said. Does the Minister know that many London hospitals, of which Chelsea and Westminster is a good example, are helped by valuable volunteers? However, no centrally collected data on volunteering are available in the NHS. If the Healthcare Commission asked trusts how many volunteers they had and what roles they played, it would be very useful.

I hope that the Minister will take up the challenge of improving prison health, which is now the responsibility of the NHS. Many large prisons in the London area have inmates who have mental health problems or abuse drugs. They have seen an increase in blood-borne viruses, tuberculosis and sexually transmitted diseases. Health staff in prisons need all the support they can get. I wish the Minister every success in his new position. I was going to say many things this evening, but due to the limited time available, I decided to write to the Minister about them. One of the issues that I intended to raise is patients who, having been transferred to a hospital specialist, have to be transferred back to the GP and then back to a hospital again if they need to see a further specialist. I hope that the Minister will be able to do something about that. We are delighted to have him here.



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7.44 pm

Lord Winston: My Lords, I congratulate the noble Earl, Lord Howe, on ably introducing this important debate with his usual words of wisdom and care, which are much appreciated in the House. It is good to see my noble friend and, if I may say it, colleague on the Front Bench. That he is a colleague from Imperial College is apt to my declaring my interest in this debate. His presence here is very good news, and I hope that he will be able to improve our health service in due course.

His report is full of aspiration, which is to be commended. However, the inequalities in healthcare in London will not be solved by the NHS. As we well know as medics, those inequalities are solved mostly by changes in the environment, by alleviation of poverty, by better education and, to some extent, prevention of disease, on which the report focuses.

I do not have time to talk about much of what is in the report. I am a little concerned about obstetrics. Only in the past week, two opposing positions on the value or safety of home delivery have been argued in the British Medical Journal. There is no clearly stated evidence yet that it is truly safe. The health service faces massive legal costs for babies which are seen by the courts to be damaged. I am concerned also that continuity of care may not be offered to obstetric patients who may be treated first for their gynaecological condition or their fertility problem and have to go to different health authorities for their treatment. That is certainly a problem at Hammersmith, where I used to work.

I am concerned, too, by mental health care. A key issue in London on which the report does not focus is the environment for mental health patients who are in-patients. It is desperately depressing to visit a mental health ward. Many patients are probably made worse by that environment.

As the report states, London is a major city: it is one of the great cities of the world. It is also one of the greatest cities, unparalleled in Europe, for medical education. It is an extraordinary centre for research, teaching and training. Imperial College is probably the biggest medical school in Europe, and it is highly successful. We have University College, King’s College, Queen Mary College and St George’s at Tooting—it is an extraordinary line-up. We must recognise in London the failure to translate much of the research that takes place from the basic area. It needs to be much more focused in the future if we are to go forward with healthcare. The report had trouble mentioning translating research; it mentions MRI and penicillin. Huge gaps need to be addressed.

There is a crisis in the confidence of people going into academic medicine, which is severely threatened. Listening to this debate is a medical student from Imperial College who, like so many of her colleagues, is thinking of doing her PhD not in London, but in the United States, because she is so disenchanted by her prospects.

We might be well advised to consider bringing back the old method of training junior hospital doctors. Perhaps my noble friend will think about it.

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The FIRM system had a lot to recommend it. I understand that appointments to it were likely to be biased and subject to misplacement, but it would be unwise to give up completely the advantage of working in a unit where doctors covered for each other and had a team responsibility. It was deeply important when I was training, and it still is.

7.49 pm

Lord Colwyn: My Lords, I thank my noble friend for initiating this debate and welcome the noble Lord, Lord Darzi, to his position on the Front Bench. In the few minutes available to me, I ask the Minister to consider the provision of dental services in London and the rest of the country. I remind him of Prime Minister Blair’s pledge in 1999 that, by September 2001, everyone would have access to an NHS dentist, no matter where they lived. Seven years later, fewer than half of British adults are registered with an NHS dentist.

The introduction of the new contract in 2006 gave primary care trusts responsibility for commissioning NHS dental services using a fixed budget set by central government. The new contract was introduced to improve access to NHS dentistry, but a recent survey of NHS dentists has shown that only one in five dentists is taking new NHS patients; four out of five restrict access to NHS treatment in some way; 80 per cent say that no new treatment capacity is available in their area; and half of all dentists are having problems meeting their NHS output targets and face financial penalties. Forty per cent of dentists would like to leave the NHS; 95 per cent were less confident in the future of the NHS than two years ago; 93 per cent of dentists believe that the new contract has done nothing to boost a more preventive approach; and 97 per cent believe that the new contract has failed to get them off the treadmill. A year after the introduction of the new contract, fewer patients are able to access an NHS dentist, fewer dentists are providing NHS care and nearly 400 contracts are still in dispute.

In the 24 months up to December 2007, 51.6 per cent of the population covered by the London strategic health authority saw an NHS dentist, compared to 55.7 per cent nationally. Uptake in London is higher among children and in this period 65.3 per cent of children visited an NHS dentist compared to 47.8 per cent of adults. This compares poorly with the national average where, in England, 70.5 per cent of children and 51.5 per cent of adults visited an NHS dentist. There is a variation in uptake across the capital, the highest being Hounslow, where 69.4 per cent saw an NHS dentist and the lowest being Kensington and Chelsea, where just 21.6 per cent saw an NHS dentist. There are 50 dentists per 100,000 population in London compared to a national average of 41 dentists per 100,000 in the rest of the country.

I have carefully read the Minister's recent reports: A Framework for Action, published in July, and, last week Our NHS, Our Future. The Minister is a doctor, not a politician, so in his new position I am sure that

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he will have been looking for some practical answers to the serious problems in the dental services and the difficulty of access to an NHS dentist. In his summary letter to the Prime Minister, he said:

That is very commendable, but then I find that in the 133 pages of A Framework for Action and the 54 pages of Our NHS, Our Future, I cannot find a single word—not a single reference—to any part of the dental service. The clinical working group membership lists 124 medical specialists and advisers—not a single dental expert or dental viewpoint. There are about 120,000 people working in NHS dentistry, including nurses, receptionists, practice managers and technicians. Do they not deserve any recognition or representation, or planning for their future? Are the Government planning to remove dental treatment from the NHS?

I shall look forward to future debates with the Minister. He will be a great asset. But in this House his remit includes dentistry, and I am not going to let him forget it.

7.52 pm

Lord Rea: My Lords, I am very grateful to the noble Earl for giving us this opportunity to explore my noble friend’s framework for London and giving him a chance in his maiden speech, to which we all look forward, to defend his plan.

Of the 45 years that I spent as a student and practising doctor, 39 were in London and 25 of those as a GP in a health centre, so I am only too well aware of London's health problems. The 122 members of my noble friend’s working groups, of which 57 were clinicians and 10 GPs, have outlined London's problems clearly, particularly in recognising the existence of widespread areas of social deprivation, with poorer health and greater healthcare needs. But I am not sure they have sufficiently emphasised the extent of these extra needs in populations with higher than average proportions; for example, of asylum seekers with linguistic difficulties, high levels of drug and alcohol abuse, acute housing problems and social breakdown. As my noble friend Lord Winston said, most of those problems are well outside the reach of the health service.

In my three remaining minutes I shall speak about primary care and the proposed polyclinics. The term suggests to many people a rather impersonal form of care. In fact, one of the main concerns of the BMA and many others is that the much valued doctor-patient relationship will be damaged in a polyclinic setting. This view was expressed vividly by Dr Iona Heath, a former colleague, in a recent BMJ article, “The Blind leading the Blind”. Apart from provocatively asking why a tertiary care specialist should be redesigning primary care, she questions whether a polyclinic is the right setting for a patient with complex medico-social problems, for example, who may be intimidated by a large institution. If

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polyclinics—or whatever name they are finally given—are going to be built, it is important that they are designed in a patient-friendly style. It makes economic sense to unravel and deal with patients with multiple problems at a local level rather than letting them bring their multiple symptoms to block A&E departments.


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