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Last year, I submitted 25 cases, all of which I had checked personally, to the noble Lord, Lord Hunt of Kings Heath, then the Minister responsible. I will detail what happened to just one. An 80 year-old man was admitted to hospital after a heart attack. He was in an advanced stage of motor neurone disease. The staff were told that but never helped him to move at all. When he needed the lavatory, he called repeatedly for help, but was totally ignored. After about two hours he wet the bed and felt ashamed and upset, which saddened me. That was not the only complaint. Food brought to him was always placed out of reach. He begged for the plate to be placed nearer but he was ignored. The food was removed untouched and after

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quite a short while he became very weak and suffered bed sores, which his wife dressed because no one else did. The family demanded his discharge from hospital and he was sent home in freezing weather, with only a very thin cover, arriving extremely cold. He died a week later.

I will read the trust’s report on that complaint. It says:

whatever that may mean—is now in place and there is,

The report goes on:

Are they?

That was all that was said in answer to my specific complaint. There was no word about help with the bed sores; not a syllable about lack of attention when the patient needed the lavatory; no comment on food being put too far away; and no word about a lack of a warm cover in the ambulance. There was no apology and no acknowledgement of any poor care at all. The final word by the chief executive on all my 25 cases, some of which apparently received no investigation at all, is in the final sentence of a three-page letter, bringing all my complaints to a close. The chief executive said:

that is rich—

If anyone can link any part of the complaint that I made about Mr Smith in that Suffolk hospital with the answer that I received, I will give them a small prize, if not a large one.

Of course, all hospitals hate to admit that they are not always perfect and in a thousand ways, of course, they do an excellent job most of the time. I am not trying to be accusatory, but to ignore unpleasant allegations of bad treatment of sick people and to go on and on because it is embarrassing to admit that it is happening really cannot be permitted. I give warning that such complacent blindness will not silence me or other colleagues in all parts of this House who are concerned about this matter—there are battles ahead. With all my heart I wish the noble Baroness a good and, I am sure, successful time in her office. She has my trust and my admiration. I hope that she will listen to what I have said.

3.05 pm

Baroness Emerton: My Lords, I thank the noble Baroness, Lady Eccles, for initiating this debate and for her very important contribution. Today there is much evidence of excellent care being delivered in the NHS. However, there is also evidence, as we have just

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heard, of poor quality care that attracts public and media attention as well as published reports from the Healthcare Commission and the professional regulatory bodies. Inevitably the spotlight highlights poor quality.

I declare a background in nursing. My passion in life is to see an improvement in the quality of patient care both in hospital and in the community. Delivery of care is by the multiprofessional healthcare team, each member having an important role to play: doctors, nurses, and midwives, and the professions allied to medicine. However, evidence points to the fact that 80 per cent of patient care is delivered by the nursing staff.

The noble Baroness, Lady Shephard, referred to the increase in the allocation of funding. Between 2004 and 2007, the numbers of nurses and midwives on the effective register had increased by a total of 26,400 making a grand total of 686,886 nurses and midwives, but we still see shortages. So where does the root problem lie? The recommended ratio of registered nurses to support workers should be 65 to 35, but the recent NHS Healthcare Commission report on the Maidstone and Tunbridge Wells NHS trust stated that 14 out of the 20 wards were below the recommended ratio. Evidence shows that the quality of care to patients suffers if there are insufficient registered nurses delivering care.

I was recently invited to visit a trust in north-east London that had a huge financial deficit, a very high level of nursing vacancies and poor staff morale. During the visit, I met 24 matrons from the trust; I spent two hours in discussion with them. They admitted that they had been demoralised, but things were improving under new management and gradually they are being remotivated. They expressed the view that the background stemmed from understaffing, lack of clarity of roles, and lack of authority. They were unable to introduce simple changes to improve patient care because their accountability was to a middle manager who held the budget. They quoted a history of a high incidence of bed sores and traced one of the contributory causes to the very poor state of the linen. That was not rectified until the new director of nursing arrived. Within a short time, 40,000 new sets of linen were ordered. The concern of understaffing was being addressed and an advertisement brought forth 250 newly qualified graduate nurses. All of them were given a simple numeracy task to calculate drug dosages and a short written answer to plan a patient care pathway. The result was that only two passed with 100 per cent, showing that only two were safe to carry out the administration of drugs.

The third person I spoke to was a modern matron in the south of England. He observed:

A great deal has still to be achieved. There has to be a culture of care from the bed to the board and the

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board to the bed. Board members need to know what happens to the patients in terms of the quality of care being delivered and not just concentrate on the finance and targets so that the service can be a cost-effective and care-effective service.

I now speak with great passion on what patients and the public really want to see: an identified person at board level accountable for the performance management of care. Many patients would say “Bring back the matron”. The Government might respond by saying, “We have brought back matrons”. Yes, but with no clear authority or accountability in many places. The trend, yet again, is for some trusts to appoint a nursing adviser to the board, not an executive director of nursing.

The nursing profession has suffered for the past 20 years as the result of the introduction of general management. There must surely be a need for an executive director to be accountable for the performance of care. This could be the nurse, or a psychologist in a mental health trust. Is it not time to right the wrongs of the past 20 years in the interest of improving quality and safety for patients by adopting the recommendations so clearly set out in the report commissioned by the Burdett Trust for Nursing, Who Cares Wins: Leadership and the BusinessofCaring?

I welcome the Minister to her seat and wish her every good wish. Can she please agree to see that this proposal is forwarded to the noble Lord, Lord Darzi of Denham, for inclusion in his final report? I am sure patients, the public and the nursing profession would more than welcome this important step in taking the NHS forward towards, in the words of Sir John Tooke, “aspiring to excellence”, and the vision of the noble Lord, Lord Darzi, for a world famous health service.

3.11 pm

Lord Haskel: My Lords, I, too, welcome this opportunity to call attention to the quality of care given in the NHS. My noble friend Lord Rea spoke of the USA. I have recently returned from an extended visit there, where the debate in the primaries is about who can afford to be ill and who can afford insurance. Those that have insurance are concerned about whether it will cover their possible illness. Quality is absent from the debate. So I welcome a debate where a publicly funded service is common ground. The NHS should not be there for opportunist politics. It is part of the progressive consensus which means that policy should be principled, based on our values and aspirations. I congratulate the noble Baroness, Lady Eccles, on setting this tone when opening the debate.

There seem to have been two important recent announcements about our health service: first, the review announced in June to be conducted by my noble friend Lord Darzi; secondly, the announcement in July by my right honourable friend Alan Johnson that there will be no further centrally directed top-down restructuring in the foreseeable future—the kind of thing which concerned the noble Baroness, Lady Eccles. The Minister confirmed that the purpose was to enable the NHS to keep up with the changing

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demands and expectations of patients: to adapt to change, to the ageing population and to the unexpected rise in childbirth.

My noble friend Lord Parekh and the noble Baroness, Lady Shephard, gave us details of the unprecedented levels of government investment in the NHS. It is only right that this should happen. After all, we have a population that knows what it wants, and wants to choose. We know that we have a population that wants to choose about end-of-life care. Is the health service being responsive to the changing needs, attitudes and expectations of these users?

Noble Lords will be pleased to know that I am not going to go over all the arguments. We debated them thoroughly when we debated the Bill of the noble Lord, Lord Joffe. My point is that if 80 per cent of the population want this choice—and your Lordships’ Select Committee confirmed that figure—then end-of-life care must be included in a review dedicated to responding to the needs and choices of NHS users.

I hope that the Minister will not say that the review will not consider the option of medically assisted dying for terminally ill patients on the grounds that it is currently against the law and that this is therefore a matter for Parliament and not the Government to decide. I congratulate my noble friend Lord Darzi on being rather more open. His response to the Dignity in Dying campaign was to invite its members to get involved in the review; presumably to develop a more patient-centred approach to end-of-life care. If the NHS develops a more patient-centred approach, then Parliament can be more supportive and more willing to change the law.

I put it to the Minister that it is entirely in keeping with the stated aims of keeping up with the changing demands and expectations of the public that there should be a system for recording a personalised end-of-life care plan; a plan which enables people to express the treatment and care that they want, including assisted dying. Of course there should be a co-ordinated, consistent and continuous use of existing best practice techniques. At the end of life, people often have more than one medical condition; it is rarely a simple battle. This choice—with safeguards—is what the majority of the population want. I put it to the Minister that this is entirely in keeping with the stated aims of her department's reform.

3.16 pm

Lord Colwyn: My Lords, I had not intended to take part in this debate, so well introduced by my noble friend Lady Eccles, as my inevitable reference to the current situation in the provision of NHS dental services has been on the Minute under “Other Motions for Debate” for some while, and I hope to have a time allocated for more comprehensive debate on this important subject in the near future.

I changed my mind last Tuesday when I saw the headline in the Daily Express which said:

Apparently, 11 million British adults have not seen a dentist in the past two years because even a check-up is too expensive. The article then posed the question

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that I have asked successive Departments of Health for more than 30 years: why can the public have all their medical treatment free, but have to pay for their dental treatment? It is simply not acceptable that dental care has become a luxury for those who can afford it. Dentistry is not, and never has been, “free at the point of delivery”.

The issue that must be resolved is why the Government and the Department of Health believe that NHS dentistry is getting better while the patients, dentists, dental staff, technicians, the British Dental Association, the Dental Practitioners’ Association and everyone connected with the provision of dentistry believes that it is getting worse? The recent survey on access to NHS dentistry by Citizens Advice prompted a warning from the BDA that primary care trusts and dentists must be properly supported if the Government are serious about improving access for patients. Its survey suggested that 7.4 million people in England and Wales have not been to an NHS dentist since the implementation of the reforms in April 2006, with approximately 2.7 million of those patients going without treatment altogether as a result of problems in accessing care.

Perhaps the issue will be resolved by the Health Select Committee in another place, which is currently inquiring into dental services. I welcome its inquiry, although it is clear to me that the members of the committee were almost as perplexed as patients when it came to understanding the systems of charging for dental treatment and for payment of dental practitioners. I remind your Lordships that the previous minimum charge of £6 has risen more than two and half times to £15.90. The dentist is paid according to the number of units of dental activity he does, which does not reflect the amount of work done or the time taken to do that work. The value is set as a reflection of work carried out in previous years and can carry a different value for individual dentists in the same practice or in different parts of the country. The accumulation of a fixed total of UDAs for each year is set, and if the target values are not reached, PCTs can demand repayment. In 2006-07, 48 per cent of practices did not achieve their UDA targets. That is becoming a serious problem for many practices, and I am aware of dentists who cannot cope with the stress of the claw-back and the potential reduction in future funding. That is why there is a continual drift into the private sector.

The department also underestimated the patient charge revenue resulting in a £159 million shortfall in the dental budget. To commission dental services successfully, PCTs must have the right resources in terms of funding and expertise and engage with local dentists and patients. The varying success with which PCTs have been willing or able to do that has resulted in a new postcode lottery of NHS dental provision. The difficulty faced by some PCTs when commissioning dental services results from their budget being based on previous spending levels, therefore areas which were historically underfunded before the new contract continue to be so. The theory is that areas of deprivation could have higher value UDAs to attract practitioners into those areas. The BDA has called for the Government

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to allocate full dental budgets for PCTs so that they are no longer reliant on patient charge revenue. PCTs were forced to cover the deficit by a combination of commissioning less dentistry and implementing inflexible performance targets for dentists. Reliance on patient charge revenue ensures that PCTs’ dental commissioning budgets remain unpredictable for future years. This funding predicament faced by PCTs comes in the wider context of the chronic underfunding of NHS dentistry, on which less is spent now than in 2002-03.

Most dentists work in a mixed economy, providing both NHS and private care. The relationship between the two is complex, and many practices effectively use private care to subsidise NHS work. The move towards the private sector is prompted by the opportunity to spend more time with individual patients and focus more on prevention. Most dentists do not experience any significant increases in income.

As I have said in previous debates, there are about 120,000 people working in NHS dentistry: dentists, nurses, receptionists, practice managers, technicians and members of the community service. They all want the NHS to work. At a time when £100 billion is going into the NHS, patients should not have to pay for private treatment, travel miles, go without dental treatment or use superglue to fix teeth or pliers to pull out loose teeth. The Government must listen and act urgently.

3.22 pm

Baroness Masham of Ilton: My Lords, I thank the noble Baroness, Lady Eccles of Moulton, for giving us the opportunity to debate the most important aspect of the NHS: the quality of care it gives to patients. Recently it has become ticking boxes and establishing what the costs will be, not putting the needs of patients first. The Department of Health has asked the noble Lord, Lord Darzi—Professor Darzi—to carry out the NHS review. The Secretary of State for Health said:

He also said that patients will have a choice of where they are treated. I agree with all that, and I ask the Minister to explain how it will be achieved.

What patients need more than anything when they are treated in hospitals or community settings is the correct diagnosis. Why do many patients have to wait two weeks for the results of a chest X-ray or a blood test in such places as Maidenhead? When my son became ill in Panama recently, he got the results of a blood test within 24 hours. Surely we can do better.

I now speak as president of the Spinal Injuries Association to say that many of its members are concerned about the difficulties that the National Spinal Injuries Centre at Stoke Mandeville Hospital is having coping with the number of patients needing specialised care. I was a patient in that unit at that time of Sir Ludwig Guttman. He pioneered the specialist treatment for paraplegics and tetraplegics, who do not feel from their lesion down and who have

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special medical needs and nursing care involving bowels, bladders, skin care and the very specialised problems of autonomic dysreflexia—this is to do with blood pressure. Doctors, nurses and physiotherapists came from all over the world to train at that unit. My very good friend Lady Darcy de Knayth had great trust in that spinal unit, as do many others. I was so sorry that she was unable to go there, which was her wish. What does this say about the Government's choice of five hospitals for patients?

After a meeting yesterday with the health Minister, the noble Lord, Lord Darzi, I see a glimmer of hope, as he has promised to look into the problems at the spinal unit. I hope that he can restore it to its former high standard of care with dedicated leadership, which is so needed. At the moment, it seems to have no slack in the system and, with bed blocking, it cannot take emergencies—a very worrying situation.

So many improvements are needed in NHS care, one being nourishing, appetising hospital food to help patients back to good health, and nurses who will give TLC when helping them to regain strength.

I end by saying how horrified many people were when they heard that Jessica Randall of Kettering had died at 54 days-old after 30 members of staff failed to protect her from abuse and murder by her father. Surely someone should have been taking responsibility. The Government have the responsibility. There was a total lack of leadership. Have we learnt nothing from the huge inquiry into the case of poor little Victoria Climbié? We must become a more caring nation, and so many aspects of health care must be improved.

3.26 pm

Baroness Howells of St Davids: My Lords, the debate of the noble Baroness, Lady Eccles of Moulton, gives the House an opportunity to look specifically at one of the Government’s manifesto commitments: healthcare at the point of need. Like other noble Lords, I thank her for this opportunity.

With the indulgence of the House, I begin by contrasting two stories, one from a poor country and the other from Great Britain. I was in Grenada during the Recess. A young child of six was badly bitten by a dog. Immediately, there was a great panic, with everyone giving a view of what should be done. I joined in and said, “Call an ambulance”—there were blank stares—“get him to the medical centre”. The mother looked at me and said, “I can’t afford it. If I call the doctor, I will have to pay him and pay for any medication”. Needless to say, I paid.

Returning here, on Sunday after Mass at my local church in Greenwich, I entered into conversation with one of the parishioners, as one does. I said, “How is your husband?”. She said, “Did you know that he had a heart attack while you were away?”. “How is he now?”, I asked. She said, “He’s doing very well. The hospital was marvellous. He was there in 10 minutes and they saw him straight away. They were so good to me and my family. The doctor told me that he was a lucky man to be alive”. I asked, “How much did it cost?”. She said, “Nothing at all, it was all on the

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NHS”. He will be there for at least another week, and we are all relieved to see the great improvement in him.


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