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There is a shortage of midwives, and with a high proportion already in their early 50s it should be made more attractive to temporarily retired younger midwives to retrain. The Government’s announcement last Monday is welcome. The magnitude of the problem is reflected in the numbers; 4,000 extra midwives are to be recruited over the next three years. It is tempting to ask why the shortage was allowed to become so great before the Government took action. Every effort should be made to ensure that the problem is solved within the proposed three years.
Patient-support staff are an essential part of the ward team, as there is so much that they can do for the patient. Nutrition plays such an important part in recovery, and if wards are well supplied with trained support staff, they can do so much towards helping and encouraging patients to eat. Of course, nutritious and appetising food does help.
Before leaving the hospital scene, I will say a word about MRSA. Hospital-acquired infections and the way in which each successive strain of Staphylococcus acquires resistance to current antibiotics make a fascinating study from the advent of penicillin in the 1940s onwards. However, we are where we are, and every effort has to be made to combat this nasty onslaught on our hospitals. It is widely accepted that the main transmission of Staph. is on the hands. Deep cleaning is fine, and it is good to have clean hospitals, but we all know that it is not the only answer. For instance, in countries where they have lower bed occupancy, they are more successful in controlling the spread of infection. Pre-admission screening, allowing enough time between admissions for thorough cleaning, and rigorous hand washing cannot be stressed too emphatically.
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I have commented on several specific areas of healthcare, which are a very few among a great many. I will end with a general point of great importance. The Government must always bear in mind David Nicholson’s aim that decisions will increasingly be made at the local level rather than at the centre. For a publicly funded National Health Service, there will always be some targets, and centrally imposed targets have a genuine place in the area of public health. Beyond that, however, national targets should relate solely to outcomes. Of course, any trust or PCT should be free to set its own internal targets if it wishes. The temptation by the centre to micromanage must be resisted. There will be tension between allowing local initiative and enterprise to develop and achieving and delivering the same standard throughout the country. Maybe we should be more relaxed about equality of provision and postcode funding and give more rein to local initiative and enterprise, which would be a great morale raiser. I beg to move for Papers.
2.36 pm
Lord Rea: My Lords, I thank the noble Baroness for introducing the debate. I find that I agree with almost everything that she said in her very constructive and wide-ranging speech. I am in a difficulty, because I came in thinking that I had 10 minutes in which to speak. In the past half an hour, I have done a rapid hatchet job, so I apologise if my speech is a little disconnected. The noble Baroness has chosen a subject that could occupy a seminar for several days and there would still be much more to say. To measure quality of care is not simple, but the task can be divided into subjective and objective measures.
First, on subjective assessment, population opinion polls fairly consistently show that the majority of people in the UK are pleased with the care that they receive from the NHS. In a speech last year, the Secretary of State mentioned a survey in which 92 per cent of patients described the treatment that they received as “good”, “very good” or “excellent”. Perhaps surprisingly, 83 per cent of people appeared to be satisfied with existing hours of GP availability.
It could be said that most people in the UK do not know any other health system with which to compare the NHS. They do not know that doctors in France give longer consultations, or that hospitals in Germany are better equipped. On the other hand, Americans can hardly believe that we have such a humane and excellent health service, free at the point of use, compared with the heavy financial burden and anxiety involved in obtaining medical care in the USA. Most of my friends and relatives who have experienced NHS care for a serious illness are full of praise for the standard of clinical and nursing care that they have received. That is more than can be said for some private care. Three of my close relatives have received substandard care in prestigious, expensive private hospitals in London.
Of course, the National Health Service has problems, as the noble Baroness mentioned, the higher level of hospital-acquired infections being one. We all know that poor care is sometimes given and that mistakes are made, some of which receive media attention, where too often the problem is presented overdramatically
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Turning to more objective measures of health and healthcare—which are not the same thing—I will share with noble Lords some of the information in this fascinating statistical document on the health of OECD nations. I am afraid that we do not do very well. We are eighteenth out of 27 countries in our infant mortality rate and our rate of low birth weight. That is disturbing because the consequence of low birth weight is a higher incidence of cardiovascular disease in later life. We are approximately half way down the list for heart disease and cancer. But we are showing signs of improvement, partly due to the national cancer plan and the NHS frameworks. The trend is towards an improvement in heart disease, but it is too early to judge the effect of the national service frameworks.
It is recognised that many of these disabling conditions are a result of multiple social, economic and nutritional factors well beyond the reach of the National Health Service. Reports by Derek Wanless and more recently by the Foresight initiative on obesity have pointed out that our major health problems have complex causes that cut across the responsibilities of several government departments—not only in health, but education, transport, housing, employment, trade and industry, and ultimately the Treasury. All legislation by these departments should be subject to a health impact assessment.
In my final minute, it is appropriate to discuss briefly what is in today’s newspapers on the National Audit Office report on the progress of the contract in primary care. In the quality and outcomes framework that forms the basis of this, doctors are given the option of adding to their income by fulfilling certain activities which constitute high-quality care. Many of these concern the identification of patients at risk of developing the kind of chronic diseases that I have described, which constitute our major health burden, and arranging appropriate care for these patients. Examples are diabetes, hypertension, obesity, cancer secondary prevention, heart disease and asthma. Many of these procedures would be carried out in any case by a good medical practitioner, but the less enterprising who would not have carried out this activity have been encouraged to do so. They have been given a cash carrot and most GPs with this incentive have performed beyond expectation—hence earning higher incomes than expected. It has been estimated that the quality and outcomes framework activity will lead to the saving of 9,500 heart-related problems.
However, I am not a wholehearted supporter of the GP contract. The BMA outsmarted the Department of Health in the pricing negotiations. I look forward to reading the full National Audit Office report.
2.42 pm
Baroness Shephard of Northwold: My Lords, I congratulate my noble friend on securing this debate and for the exemplary way in which she has introduced an enormously broad subject. I pay tribute to the expert remarks of the noble Lord, Lord Rea.
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The Minister, whom I welcome to her place today, will certainly in her closing remarks—otherwise I shall be very surprised—remind us of the increases in spending on the NHS in the past few years. I expect her to tell us, for it is the case, that annual spending now amounts to more than £92 billion and that the proportion of GDP devoted to health spending has risen to some 9 or 10 per cent of the total. She may also describe some of the welcome policy initiatives introduced by the Government, not least the reduction in waiting times, and she would be right to do so.
However, she will know, as do the rest of us, that while the amount of money spent is all important, the way in which it is spent is also important. Given that it is our money, perhaps it is even more important. Last September’s King’s Fund report pointed out,
- “what is clear is that thus far the additional funding has not produced the improvements in productivity assumed in the 2002 review—costs of providing health services have increased and there is patchy and conflicting evidence on the impact on productivity overall, including little information about community-based care”.
This is important for Ministers because while the public hear what they say about extra cash for the NHS, it is the public’s experience of services on the ground which will form their judgment of the Government’s performance. The noble Lord, Lord Rea, mentioned that only today the National Audit Office has confirmed what some of us suspected about the GPs’ contract—that it has given GPs a great deal more money for doing less, or, rather, for doing things in a different way; and into the bargain it overspent by some £1.75 billion pounds. I suppose that Ministers accept that, because they are to renegotiate the contract.
In Norfolk, one of the early effects of the contract was to cut GPs’ out-of-hours services, thus driving a coach and horses through the concept of community care and putting more pressure on A&E services. Norfolk people are also aware of the cuts in beds and staff and some 400 cancelled operations in the past two months at the Queen Elizabeth Hospital, King’s Lynn, giving what one consultant at the hospital called,
as the hospital struggles to meet its debts. I hope that the Minister does not feel that these remarks are deliberately churlish. I have paid tribute to the extra funding of the NHS, but I would remind her—and one was constantly reminded of this when one was in government—if people pay higher taxes, they expect to see more and not fewer services on the ground. That is the point made by the King’s Fund report.
All of us in this House are particularly proud of the fact that the NHS review is being led by the noble Lord, Lord Darzi, for whom there is enormous respect here. Will the noble Baroness be in a position to lift the curtain a little on what might come out of the review? I ask her these questions in particular: how, if the report stresses the importance of community-based care—as I am sure that it will—can the disparity of funding between NHS and social services funding be reconciled, when dealing with the same client groups? What will be the policy for small community hospitals? The present policy seems to be closure, which is deeply
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I am limited by time constraints. Unlike the noble Lord, Lord Rea, I had some warning, but perhaps I may sum up: terrific on resources; jury out a little bit on their effective use.
2.47 pm
Baroness Murphy: My Lords, I add my thanks to the noble Baroness, Lady Eccles, for introducing this debate and I agree with her themes of devolution and quality. I have experienced recently the best and the worst quality of care for very aged relatives, and I know how distressing it is when it does not work well. I have also given the best and the worst care in my clinical years and know how complex it is to get it right.
Getting quality right is not just a UK problem. Let us face it, there are quality problems—particularly on quality of outcome—and care failures around the globe, including in the much-vaunted US system. But, there is no doubt that our directly managed structures in the NHS positively divert clinicians and managers from sick patients’ priorities to feed the beast of governmental process targets which are largely meaningless to clinicians if taken to extremes. We would have to be stupid to think that the recent disaster in the Maidstone and Tunbridge Wells NHS Trust was a one-off; there was nothing unusually poor or wicked about either the clinicians or senior management there, they were just worrying about something else. Things are very bad in other places, but they are not as conveniently measured as C. difficile cases.
I am a board member of Monitor, the NHS foundation trust regulator and make no apology for talking today about our view on what it will take to improve quality across the NHS. I define quality as safety, clinical outcomes and patient experience. The answer lies not just in providing those incentives for providers, but in changing commissioning. We know that if we get joint commissioner-provider incentives and sustained priorities, we can make significant progress; waiting times are a clear example. Too often, we have had too many inconsistencies, too many themes, and not enough time to change. If we want quality to improve, we have to make it the absolute priority and stick with that. That will require major political support for the sort of reconfigurations that I hope the Darzi review will recommend in order to reduce the variability. We need public support for that, which will be by ensuring that they have the information. Performance league tables in education
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I want to talk about primary care trust commissioners, because they are in a mess. What were the local Maidstone PCT commissioners doing, frankly, when buying such lousy care from the trust? The answer is that they were navel-gazing while being reorganised. PCTs must be held accountable by SHAs for the quality of the care they purchase. It requires performance regime change; instead of focussing on in-year finance and access, they must focus on quality of outcome. That means investing in skills; at the moment we spend half a percent on investing in commissioning skills. Any health insurer in the rest of the world spends about 5 per cent, minimum. A medium-sized health insurer would have, perhaps, 15 to 20 trained actuaries for risk and pricing analysis, but PCTs have none. It is about buying clinical services and yet clinicians are not involved. There is almost no clinical leadership in PCTs; that needs massive development and expansion. About 90 per cent of the 350,000 PCT employees are employed in provider services, even though that accounts for only about 10 per cent of their budgets, while only 2.5 per cent work on commissioning, which accounts for 90 per cent of their budgets. Will the Government now crack on with the separation of provider and purchasers in PCTs, and concentrate on the job that they are supposed to do?
We need outcome and quality standards: probably a mixture of process and outcome metrics, which we already have on mortality rates, readmission rates, patient satisfaction, infection rates and so on. We must have information down to individual clinician level. In fact, much of that is already available. There is also a great deal more that we could get out of patient surveys, although at the moment we do not survey the very patients who are most at risk of poor quality, such as the confused older person entering hospital, nor their carers who could give us a pretty clear picture of how they felt about their times there.
On incentives, briefly: we know that we have public-funded services such as the HEFCE way of funding, through the research assessment in universities, which is excellent in that respect and which we could easily replicate. I am running out of time, so I will just say that we can address these matters easily if we give priority to quality in the way that it deserves.
2.53 pm
Lord Parekh: My Lords, I begin by congratulating the noble Baroness, Lady Eccles of Moulton, on securing this debate and introducing it so very well. There is no doubt at all that the NHS has improved considerably during the past few years. The infrastructure has improved, staffing is better than before and the basic NHS culture is undergoing some extremely important and desirable changes. I welcome all that and the fact that our expenditure on the NHS is increasingly coming up to the European level—something like £43 billion during the past five years alone.
I have only about five minutes when I had expected to have more, so, having congratulated the Government, I want to concentrate on where the NHS needs to go
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First, it is striking that there is a great deal of inequality between different regions and different socio-economic groups in life expectancy, infant mortality and general quality of life. If we are not careful, that will increasingly become a bone of serious contention, even protest.
Secondly, as my noble friend Lord Rea pointed out, the National Audit Office has confirmed that the additional funding that has gone into the NHS has not produced the commensurate and expected level of improvement. Partly that is because too many administrators, as opposed to doctors, have been involved and there has been too much paperwork. There have also not been, I am sorry to say, properly negotiated contracts with GPs. Quite a lot of money has gone into GPs’ pockets; I do not begrudge them that, but at the same time it has not resulted in the kind of improvements that one had hoped for.
My third point is slightly different. The NHS will always be short of resources, but how do we tackle that? One way is to control not just the growing administrative hierarchy but one or two other areas. Millions of pounds-worth of medicine are wasted and we need to find ways of reducing that wastage by greater prescriptive self-restraint on the part of GPs and greater public awareness. We could also, perhaps, ask drug companies to produce drugs so that if I were to use a part, the rest would not be wasted but could be reused. I know that that is being done in some countries.
Equally important, I have always been struck by this: why have we not, during the past 50-odd years, developed the culture of philanthropy that characterised the Victorian age and is to be found in other societies? In many countries, when people die, they are prepared to leave a part of their money to colleges, universities or schools. Why is that practice not extended to hospitals? Why would people not say, “Look, I want to donate for equipment”—or for a bed, or to build a room, or to endow the post of a consultant or registrar—when some are in a position to do that? That culture of philanthropy exists in other countries. That is what characterised our own country during the Victorian period, but I can say, from some experience, that it is also to be found in parts of India. With suitable tax breaks, it should be possible to encourage a culture of medical philanthropy in our country. I would have developed this further if I had had time, but I shall rest the general point there.
We should also improve the efficiency of communication between hospitals and doctors. Let us take something simple. A GP refers you to a hospital doctor for an X-ray, a throat swab or a blood test. The hospital report takes days and days to arrive and in the mean time the poor GP is paralysed and the patient continues to suffer. I am sure that it should be possible to organise things in such a way that, within 24 hours of a test being done, the hospital can phone the GP and say, “These are our findings; please treat the
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I have one other point, which is structural. In this country, there is a tendency to think in terms of bipartite structures. We had universities and polytechnics; we have solicitors and barristers. We seem to have transferred that philosophy to hospitals, so that we have GPs on the one hand and consultants and hospital doctors on the other. I do not know of many countries where that kind of division takes place. Why it has come about here is a long story, but I suggest that it should be possible for GPs to become semi-experts in particular areas, if not as expert as consultants. It should then be possible to have, rather than a single GP, a group of GPs working together, with each specialising in such things as ophthalmology, ENT or cardiology, so that in-house GPs are able to provide many of those services before they refer patients to consultants. If they need certain guidance, it should be possible for them to ring up the hospital consultant and ask, “In this case, given my expertise and what I have found, what do you think I should be doing?” rather than waiting for weeks until the patient is referred to the hospital consultant.
As my time is up, and I dare not alienate my Whip, I should stop. I believe that there needs to be some radical rethinking if we are to get maximum advantage out of the money that we are spending to make our system more efficient than it currently is.
3 pm
Baroness Knight of Collingtree: My Lords, I am most grateful to my noble friend Lady Eccles for giving me a chance to raise again something very close to my heart. For over five years, ever since the Government blocked my Patients’ Protection Bill, which would have stopped the appalling practice of deliberately withholding food and liquid from sick people in hospital, I have been trying to bring an end to such inhumanity. I am shocked that it seems so difficult, if not impossible, to do so. There is no time now to catalogue the ways in which my frequent requests in Parliamentary Questions, speeches and letters to Ministers have all been stolidly blocked, although initially they have been received courteously by those Ministers.
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