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My noble friend Lord Darzi is not the first eminent specialist to tackle primary care. In 1920, Lord Dawson of Penn, a highly respected physician, produced a report on the future provision of medical and allied services. A network of primary health centres was to be set up, linked to secondary health centres—hospitals—in turn linked where possible to teaching hospitals. The primary health centres would be run by GPs, who would have at their disposal on site radiology, bacteriology, biochemistry, electro-therapeutics—which I take to mean physiotherapy in today’s terms—and assistance from visiting consultants, specialists, nurses and health visitors.

The polyclinics in the current plan would have all those features and more. Some might say that the Darzi plan is the Dawson plan brought up to date. Sadly, the Dawson plan never reached fruition; it was too ahead of its time and Lord Dawson did not have any power to apply it. However, the Prime Minister has given my noble friend, in contrast to Lord Dawson, the position—and yesterday, the Chancellor, the funds—to implement his plan. I hope that he does so wisely and tactfully, easing forward incrementally, a little at a time rather than introducing yet another administrative upheaval. He has made a good start by including a substantial number of clinicians and other healthcare professionals, who know the problems involved when drawing up the plan. He has promised to continue to be in touch with professional colleagues in the next stages, and to do so will increase his chances of success.

7.57 pm

Baroness Emerton: My Lords, I thank the noble Earl, Lord Howe, for raising this short debate on the very important subject of the challenges facing the NHS, and I join in his congratulations to the noble Lord, Lord Darzi, on an excellent report which reflects the enormous amount of work undertaken in the past months.

Changes in the delivery of healthcare inevitably bring changes in the roles of those delivering the care, and one of the greatest challenges is to provide the right number in the right place at the right time with the necessary knowledge and appropriate skills. I declare my background as a retired nurse. The nursing and midwifery professions have the largest single numbers of employees within the NHS, and it is vital that nurses and midwives are care-efficient and cost-effective.

It is pleasing to note that work is already under way in reviewing the workforce implications of the proposals, including the education and training to be required. However, it is crucial that the universities are fully involved with strategic health authorities from the beginning and not merely consulted when preliminary conclusions have been reached. Indeed, it

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is vital that non-medical deans in the universities and the Council of Deans are involved. These are the people with expert knowledge of the educational, training and research needs. However, it will also be difficult to provide for the workforce plans without agreement on the service reconfiguration. So timing is a real challenge. This review provides the opportunity, too, to repair the damage of the last two years, when the infrastructure in many universities suffered due to the diversion of funds by SHAs to rectify the NHS deficits.

Recent research forecasts that 150,000 nurses and midwives will retire in the next 10 years. Any disruption to the education and training programmes has a long-term effect not only because of the length of the training but also because of the number of institutions engaged in pre- and post-registration programmes. Paragraph 48 of the report Making the Vision a Reality recommends a rationalisation of training institutions. That will need very careful consideration and understanding of the complex interface and relationships of placements for students, as the numbers seeking placement are greater than the number of placements in the medical profession.

Will the Minister ensure that nurses and midwives with skills in workforce planning are engaged, with the appropriate knowledge and understanding of the different clinical pathways required for all the different specialities? This will ensure that the knowledge and skills requirements are fully met so that high-quality and cost-effective care is delivered to patients.

Workforce planning is related not just to numbers with the appropriate knowledge and skills base but to the accountability and authority vested in each role. The Burdett Nursing Trust sponsored a study resulting in a report published last November, Who Cares WinsLeadership and the Business of Caring, which could perhaps be simply described as accountability from the bed to the board. The report clearly makes the case for an executive director at board level who is accountable for the performance management of clinical care. When modern matrons were introduced, many of them had no professional accountability to a nurse but only to a non-healthcare professional. The recent announcement of more modern matrons to combat the hospital-acquired infections MRSA and C. difficile will be to no avail unless authority and accountability is built into the role from the delivery of care through to the board.

Achieving these changes raises what I consider to be the largest challenge facing any of the recommendations for change: the need for a complete culture change throughout the NHS, beginning at board level, whereby the balance between finance and care is restored instead of the current distortion in most NHS boards whereby the emphasis is on finance and targets with little evidence of patient-care delivery being an agenda item. No business can succeed unless there is customer satisfaction. This week’s Healthcare Commission report on complaints speaks for itself.



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Will the Minister reassure us that, within the implementation programmes, workforce planning, authority, accountability and culture change will be addressed so that the NHS may once again be recognised for high standards of healthcare delivered with care and compassion?

8.02 pm

Lord Haskel: My Lords, I add my thanks to the noble Earl, Lord Howe, and extend a warm welcome to my noble friend Lord Darzi. The main thing that I wish him is stamina. Being on the Front Bench and doing a job outside Parliament will require lots of it and I wish him every success.

This is not the first report on health services in London; my noble friend Lord Turnberg wrote one in 1998, and indeed the report of my noble friend Lord Darzi refers to it. My noble friend Lord Turnberg would like to have spoken this evening but was unable to do so because of a prior engagement. However, he and I discussed this report on healthcare in London. We agreed that by addressing people’s needs so directly it certainly moves the NHS in London forward. We welcome its progressive change and its proposals will ensure that the money budgeted for primary care in yesterday’s Pre-Budget Report will certainly be well spent.

Our concerns lay not with the ideas, most of which deserve support, but, as other noble Lords said, with some of the practicalities. For instance, the sequence of change is important. The noble Earl, Lord Howe, was also concerned about that. Great care will have to be taken to ensure that hospital services in London are not cut in advance of the increase in care provided by the clinics and enhanced GP services. Surely these services will have to be built up first. If they are not, there will initially be a fall in service provision.

Another practical concern is the calculation of the population requiring care. The report certainly attempts to provide for tourists, business and professional visitors and students, but what about the huge transient population of casual workers who stay here for 18 months or two to three years, many of whom are from the new member states of eastern Europe, with many living in the poor conditions that my noble friends Lord Winston and Lord Rea described? Underestimating this demand will result in a fall in service provision for everybody. This is why the population estimate will have to be generous.

Another practical consideration is the need to break down the current divide between primary care and hospital care. Surely it makes sense to get GPs and hospital specialists together to agree how care is best provided, by whom and to what standard. Surely this is the only basis on which contracts can be drawn up. An example of the problems caused by this failure to integrate can be seen in the maternity services to which other noble Lords referred. The damaging divisions between obstetrics, midwives and GPs have caused many difficulties. I agree with other noble Lords that patients need to be assured that they are

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receiving the best care for them as an individual and their baby and are not subject to the biased views of one part of the service.

However, apart from these practical considerations my noble friend presents a compelling vision for the future of health services in London. Like my noble friend Lord Winston and others I welcome its vision and aspirations. It certainly deserves our support.

8.06 pm

Baroness Barker: My Lords, on behalf of my colleagues on these Benches I too extend a very warm welcome to the noble Lord, Lord Darzi. To have in this place someone of his experience and outstanding achievement will be immensely valuable. We very much look forward to working with him. The noble Lord is renowned as a surgeon for his ability to develop minimally invasive techniques which achieve radical improvement while minimising disruption and damage. If he can apply that approach to the structure and management of the NHS, I am sure that he will command widespread support and respect.

I also congratulate the noble Earl, Lord Howe, on initiating this debate because London faces an increasingly complex number of health challenges. Some—for example high incidences of HIV, substance misuse and mental health problems—are perhaps inevitable where there is a highly diverse and mobile population. Others, such as the disparities in access to GP services, arise in part from the historical complexity of the NHS itself.

Following yesterday’s CSR announcement, we know that the NHS in London will face two additional challenges. The increase in NHS funding for the next three years will be 3.2 per cent, not the 4.4 per cent which Sir Derek Wanless stated is needed to meet the demands that his report analysed in great detail. Furthermore, the increase of only 1 per cent in funding for social care via local authorities will mean that a reduction of care services will lead to those with high dependency turning increasingly to the NHS.

The framework for action of the noble Lord, Lord Darzi, has much to commend it, not least the level of engagement by clinicians, which all too often has been lacking in many recent government initiatives. However, the report’s main strength is that it sets out a clear pathway into acute and specialist care for people with identified clinical needs. That said, I echo the comment of the noble Lord, Lord Rea, that GPs have reacted to the report with a lack of enthusiasm for the further shift of diagnostics into the community. That is somewhat surprising. It seems that they are yet to be convinced that the diagnostic shift will lead to an overall improvement in clinical pathways. I am sure that the noble Lord agrees that getting GPs on board with his plan is integral to its success. I would be interested to know how he intends to do that.

It is difficult to tell from the report how it will work in practice because much of the detail and costings are not there. I should like to know at some stage from the Minister how far his plans are realisable within the existing tariff system and what the system

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of payment by results will mean in terms of his ambitions being realised. Like the noble Lord, Lord Winston, I agree that the report is deficient in that it does not address mental health issues. That is a key issue in London for people of all age groups. I am sure that the noble Lord has taken that on board by now and will address it when he rolls out his plans across the rest of the United Kingdom.

Yesterday, the Government announced a Green Paper on the future of social care. That is very much welcomed by these Benches because it is only by addressing how we support an ageing society with people with long-term care needs that we will be fully able to assess the environment in which the plans of the noble Lord, Lord Darzi, will have to be implemented. That is important, as we have said many times in your Lordships’ House.

Finally, the implementation of this plan must depend on having a world-class IT system that enables patients to move smoothly between establishments and one in which clinicians have confidence. Does the noble Lord believe that the requisite IT support will be in place? This is an ambitious plan. Like the noble Earl, Lord Howe, we wish to be convinced of its viability. I wish the noble Lord all the very best with his attempts to get it to reality.

8.11 pm

The Parliamentary Under-Secretary of State, Department of Health (Lord Darzi of Denham): My Lords, I begin by congratulating the noble Earl, Lord Howe, on securing today’s debate on a subject that, I am sure he knows, is dear to my heart. I have worked in the NHS in London for 17 years and I am continuing to do so, as well as working in my new role as a government Minister. I owe it to the House to explain my ministerial role. I will be working as a government Minister for three days a week and operating on patients for two days a week. As most noble Lords know, I could not put down my scalpel just yet, as the desire to care for patients and to improve quality of care were the two reasons why I came into medicine in the first place.

My government role gives me the opportunity to ensure that those values of high-quality, evidence-based and patient-centred care will be accepted by all—clinicians, politicians and policy-makers—as the central principles for the reformed NHS. That is what is driving me in my review of the NHS. I will be holding regular meetings open to all noble Lords on the progress of my review, which will also, I hope, allow me to benefit from their sage advice, some of which I received today from the noble Lord, Lord Colwyn.

For those noble Lords who have been listening with interest to the Report stage of the Local Government and Public Involvement in Health Bill, I emphasise my strong belief in the importance of listening to patients, public and staff. I have already spent three months doing just that in the first stage of my national review, culminating in last week’s interim report. I will continue to listen over the next few months in the review’s second stage.



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I first took this consultative approach in my work on London, where 150 clinicians and 200 members of the public were directly involved, while thousands more gave their views in surveys and representations. What I heard led me to identify eight reasons why healthcare in London needed to change—eight challenges that need to be addressed. I do not have time to mention all of them here, and I commend my report to the House for a more in-depth consideration of the issues; a copy has been placed in the Library. Instead, let me focus on three of them: inequalities, outdated healthcare provision and public demands. Those challenges are not unique to London, but they are particularly acute in the capital and require solutions specific to a large urban area.

As the noble Earl, Lord Howe, eloquently described, London has both the best healthcare and the worst healthcare in England. Some of London’s hospitals are international leaders, while unfortunately others do not meet the expectations that we all try for. Meanwhile, the fewest GPs are found in the areas with the greatest needs, such as north-east London. Those inequalities in care are matched by inequalities in outcome, as highlighted by my noble friend Lord Warner. As he described eloquently, the journey between Westminster and Canning Town on the Jubilee Line is just eight stops, 20 minutes, a distance of six miles and a cost of £2. But the average life expectancy is seven years lower in Canning Town than in Westminster. Another example is that the infant mortality rate in Haringey is three times that in Richmond.

Equality was one of the founding principles of the NHS. As we approach the 60th anniversary of the NHS, it is a noble principle to which we must return. I have made suggestions in my report as to how I think this can be achieved, including by encouraging the best hospitals to provide services on other sites. For instance, why can we not have the excellent cancer care provided by the Royal Marsden at other London hospitals? However, a lot of London’s health inequalities can be tackled only if the NHS ensures that people stay well, rather than simply seeking to patch them up when they are ill. Improving health must therefore be part of the core business of the NHS rather than an optional extra. I am confident that the NHS will be supported in this by other public services. The Mayor of London took a considerable interest in my report and he is using its recommendations in his overall health inequalities strategy for the capital.

While we strive to reduce inequalities for Londoners, we must increase inequalities between hospitals. By that, I mean that we cannot have 31 hospitals all providing the same services. That is not a revelation. When Bevan spoke in the other place to advocate the Bill to establish the National Health Service, he noted:

Yet 60 years on, that outdated model of provision persists in London.

Stroke care is an example. Currently, 31 hospitals are providing stroke care, most of them badly. When I started my London work, we had the 2004 data that

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showed that stroke care was poor. All the clinical colleagues whom I met told me that the data were old and that things had improved. Then the 2006 data were published and the figures were significantly worse. That is because providing acute stroke care at all hospitals is outdated. It was fine in the past; when I was training, stroke treatment used to consist solely of rehab, so it did not matter which hospital a stroke patient went to. However, it is now possible to intervene and to treat strokes with thrombolytic drugs—so-called clot-busting drugs—following a rapid CT scan. Such treatment cannot be provided in all hospitals but should instead be concentrated in a smaller number providing acute stroke care to the highest international standards.

That is why my report is not about the closure of hospitals, but rather seeks to make a clearer distinction between types of hospitals. There is a need to clarify which hospitals should be providing the most specialist care to the victims of serious car accidents—as highlighted by the noble Baroness, Lady Masham—or the sufferers of a major heart or brain attack. Those should be separate from those dealing with the less critically ill. Any other approach would be detrimental to patient care. That is why I said in my London report:

For reasons that are beyond me as a humble clinician, most of that sentence is removed when it is quoted.

I come back to the very important point raised by my noble friend Lord Winston. Our healthcare provision also lags behind our international comparators in co-operation between academia and healthcare. Countries such as Switzerland and Canada have established academic health science centres—partnerships between leading hospitals and universities. They help to ensure that new healthcare innovations are transferred rapidly into improved patient care. I hope that the academic health science centre that I recommended, which is now being established by Imperial College, St Mary’s Hospital and Hammersmith Hospital Trust, will be followed by other centres of excellence across the country.

My noble friend Lord Haskel raised an important point about the division between primary and secondary care; it is another good example of outdated healthcare provision. There is a chasm between the one- or two-handed GP surgeries that make up the majority of London’s primary care practices and the capital’s hospitals. That is why I proposed in my report the creation of polyclinics. These community health facilities will provide more services, more locally. Polyclinics exist across the world, from Switzerland to Singapore, in America and Australia, so they are tried and tested. They can also provide the sufficient scale for the shifting of care closer to home that the Government envisaged in the Our Health, Our Care, Our Say White Paper. Polyclinics were also anticipated back when the NHS was established. Bevan talked about the importance of health centres with dental, maternity and

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diagnostic services on site. He even expected the infrastructure to be available for local specialist services, saying that,

My noble friend Lord Rea argued that polyclinics may depersonalise primary care and that patients will lose their personal relationship with their doctors. I say that there is no reason why this should happen. I work in a large hospital with hundreds of doctors. I still get to see my patients on a one-to-one basis.

People, especially those with ongoing long-term conditions, including mental health conditions, should be able to see a regular doctor at a polyclinic. But as well as receiving that continuity of care, they will be able to have diagnostic tests on site, have a dental check-up, discuss their care plan with their social worker and perhaps even have a meal in the polyclinic’s healthy café. Polyclinics are a viable answer to London’s healthcare challenges and I expect them to develop locally. Those suggesting that I envisage the herding of GPs into polyclinics imposed from above have missed the whole tenor of my report, which is about ensuring that change is led from the bottom up by local clinicians. Indeed, the Royal College of General Practitioners called on its members to seize the opportunity offered in my report to develop new federated models of polyclinics.


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