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As a number of noble Lords have demonstrated, any analysis of the quality of care given to NHS patients has something of the curate’s egg about it, because we can point to areas where this country leads the world in standards of care and treatment, and other areas where care is poor or even worse. From a political perspective, I have always been ready to give credit to the Government for some of their initiatives during the past 10 years. We now have national bodies whose job it is to oversee and assess the quality of care delivered in our hospitals and care homes. We have a GMC which has undergone reforms whose whole aim is to maintain professional standards and enhance the protection of patients, a process that still continues. We have national clinical directors for many of the key specialties such as cancer, heart disease and mental health. National service frameworks have been developed. Social workers are subject to registration and accreditation. We could add to that list. Nobody can doubt the Government’s commitment to wanting better standards of care for all patients. The large increase in the NHS budget is above all a testament to that.

But intentions are one thing; results are of course another. The whole point of bringing expenditure in the NHS up to the European average was to deliver the kind of healthcare that our European neighbours already enjoy. But we are still a long way from achieving that. Our five-year survival rate in cancer is worse than almost all other EU countries. We are nearly the worst in the OECD for breast cancer mortality. We are well below average in our survival rates for most common cancers, stroke, heart disease and respiratory diseases. When the Government defend their record in health, they tend always to do so in terms of inputs—how much is going into the system. But the test of success is of course outcomes; and we need only look to the words of the noble Lord, Lord Darzi—that passionate advocate of high-quality care—to appreciate how woeful is our record on outcomes and life expectancy in many parts of the country, not least many of the deprived parts of London.

When the Secretary of State took office last summer, he was refreshingly frank about the Government’s record. He admitted that doctors and nurses were fed up with top-down instructions and wanted a sharper focus on outcomes and patients. He spoke about putting clinical decision-making at the heart of service delivery. He talked about making that service responsive to patient choice. These are aspirations to which all of us can surely subscribe.

The sad part is that in so many areas of policy we see Ministers and the Department of Health continue to indulge their controlling tendencies; and the consequences of that are all too often perverse and damaging to patients. Perhaps the starkest example of these controlling tendencies is the target culture, which is still alive and kicking. Targets are blunt instruments: they tend not to distinguish between patients whose need is urgent and those whose need is

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not. And one creates a distinction between what is targeted and what is not. What is not targeted tends to become a lower priority in the allocation of resources. Patients with chronic conditions, for example, fall outside the scope of national waiting time targets, yet they outnumber elective patients by a wide margin. Clinical priorities tend to get distorted, and the price that we have paid for driving down waiting times has been to compromise standards of care, most obviously in the area of infection control. The Health Protection Agency was quite clear about this in its recent report. The agency identified one factor affecting the management of MRSA as,

“increasing patient movement between wards to meet A&E targets for trolley waits”.

High bed occupancy poses a further risk. The pressures on hospitals to deliver on their targets have undoubtedly led to an increase in bed occupancy rates to levels that are in many cases unsafe. But we should not find it surprising that hospitals are tempted to take these sorts of risk when the operating framework imposed on them by the department contains swingeing financial penalties for breaches of the 18-week target—up to 5 per cent of their elective income, a potentially huge amount of money.

The irony here is that the Government take it as a given that achieving the 18-week target is a cost-effective use of public money. As far as I know, there is no evidence to back up that assumption. The 18-week target is just something that Ministers have seized on as being a good idea. I doubt very much whether the opportunity costs associated with it have ever been evaluated, any more than were the opportunity costs associated with the recent agreement reached on the GP contract.

The Prime Minister has made increased access to GP services his number one priority for primary care. The irony of this should not, however, be lost on us, because it was this Government who, with their eyes wide open, negotiated a contract that has meant doctors have less control than before in delivering Saturday and evening services. The Government are now in the extraordinary position of criticising a situation which they created, yet blaming doctors for it instead of themselves. At the same time, they are flying blind; it was quite extraordinary to hear the Secretary of State say the other day that, despite all the pressure he is putting on GPs to extend opening hours at their surgeries, he has no idea to what extent PCTs are already commissioning GPs to open for longer. How on earth can you gauge the importance of a problem if you do not know its scale?

Many of us wonder whether the policy can in any sense be called evidence-based. The Government's latest GP-patient survey showed that 84 per cent of patients are happy with current opening hours; only four out of every 100 wanted extended opening hours in the evenings and seven out of 100 wanted Saturday surgeries. To force GPs to include opening hours as part of the QOF, instead of clear measures of good patient care, is a seriously misconceived piece of micro-management. The scope for adjusting the QOF in ways that might have improved the care of patients was enormous, not least in the area of brittle bones in the elderly, which costs the NHS a fortune and is an

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area of care that is not being addressed at all well. But that opportunity has been lost. The QOF has been misused, because access arrangements are not an outcome—and all this because Ministers have lost sight of their own worthy aspirations about devolving commissioning and choice closer to patients.

Exactly the same absence of evidence-based decision-making runs through much of the ideas surrounding service configuration. On maternity units, the Government are looking to centralise care in larger specialist units at the expense of access to smaller units. The claim that is made is that larger units are safer. Absolutely no clinical evidence has been produced to substantiate this; indeed, the Healthcare Commission has given some of its highest ratings to smaller units. What the policy means is that many of these smaller units have closed or are about to. So much for patient choice and easy access. The real reason for these closures is, of course, financial. Very similar issues arise with A&E. Units are being closed, allegedly on clinical grounds, with services being concentrated in fewer centres, but the evidence we have indicates, unsurprisingly, that the further seriously ill people have to travel by ambulance to reach emergency care, the more they are likely to die.

I am fearful that the same kind of top-down approach is going to dominate service reconfiguration more generally. The review of NHS services in London undertaken by the noble Lord, Lord Darzi, contained much good work; but it had a very prescriptive feel to it. He spoke of having a polyclinic in front of every hospital; 150 polyclinics across London; and a GP-led service at each hospital. Polyclinics may well have a place in under-doctored areas. But to make them a universal prescription, at the expense of closing down GP surgeries and perfectly successful hospital departments, really has to be justified in terms of the quality of care delivered to patients. Alternatives—of which there are a number—ought to be evaluated. I do not feel that they have been. What I wish the noble Lord, Lord Darzi, had done was to produce, not a blueprint, or a “template” as he has described it, but a menu of ideas and service models which local commissioners could then take up. Indeed, if I were to think of one message for the noble Lord, Lord Darzi, as he rounds off his nationwide review of the NHS, it would most certainly be that one.

4.05 pm

Baroness Thornton: My Lords, My Lords, first I congratulate the noble Baroness on her choice of topic for today’s debate. She and I are old friends from the Select Committee on Communications; indeed, we have even travelled through the night together. I was not surprised at the quality and thoughtfulness of the noble Baroness’s contribution. We have had a high quality debate with a wide spread of different contributions. If I fail to answer fully any noble Lord’s question, I will be happy to write.

There can be few subjects more important than the quality of care given to NHS patients, whether in hospital or in community settings. Indeed, the contributions from my noble friend Lord Rea with his

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vast experience of the National Health Service and the GP services, the enormous wisdom and experience of the noble Baroness, Lady Murphy, and her work with Monitor, my noble friend Lord Parekh and his remarks about improving communications, and, indeed the noble Baronesses, Lady Emerton, Lady Masham, Lady Greengross, and Lady Knight, and my noble friend Lady Howells present a formidable challenge to a new Minister.

I say from the outset that the quality of healthcare has improved out of all recognition since Labour was elected in 1997. I know it is the job of the Opposition to suggest that this is not the case, but I might say that today the Opposition health spokesman in another place felt the need to honour our enormous progress by making expenditure promises that seemed to, and will be bound to, upset his Shadow Chancellor’s plans, which is a testament to the work and investment of the past 10 years.

I make two points. First, I want to pay tribute, as other noble Lords have already done, to the superb work carried out, day by day and week by week, by the staff in our health and social care services. Every day, 819,000 patients have a consultation at a general practice, 122,500 patients attend an outpatient clinic, and about 60,000 patients are treated as day patients or inpatients in hospital. In the vast majority of these daily encounters with the NHS, as patient survey after patient survey demonstrates, as mentioned by my noble friend Lord Rea, patients receive and appreciate high standards of care delivered by caring professionals who have dedicated their lives to the business of improving health. We should be proud of their achievements, not take delight in knocking them, as some of the most strident of our national media seem to do.

Secondly, I pay tribute to that much maligned breed—NHS managers. Research from around the world shows that high quality organisations do not just happen, they need dedicated and clear-sighted leadership. They, too, have at heart the quality and the safety of the services which their organisations deliver. Furthermore, leadership in the NHS is increasingly being exercised not just by professional managers but also by clinicians, as mentioned by several noble Lords, who have taken on formal or informal leadership roles. As my noble friend Lord Darzi has repeatedly stressed, clinical leadership is potentially the most powerful lever for quality improvement, and we must do all we can to nurture and to celebrate such leadership.

However, I do not want merely to pay tribute to dedicated staff, clinicians and managers; I want to set out a simple proposition: that the best way of achieving even further improvement in the quality of services for NHS patients will lie in the innovation and drive of local clinical leaders, working in partnership with local managers and responding to the needs of their local populations, in an environment which supports and rewards quality. Striving for that quality lies at the heart of the review of my noble friend Lord Darzi, as mentioned by the noble Earl.

I should like to say a few words about the many elements of this supportive environment for quality care that are already in place. Clinical guidance covering most of the significant clinical conditions is

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now available from the National Institute for Health and Clinical Excellence. We have launched a major initiative to improve capacity and skills in primary care trusts to commission services although I acknowledge that work still needs to be done. PCTs will in future commission services from an increasing range of providers, including providers in the private and third sectors, to meet the health needs of their populations—that was the point of David Nicholson’s letter quoted by the noble Baroness, Lady Murphy—and they will be working closely with councils with social services responsibilities to ensure that people have access to services that are properly joined-up between health and social care.

For instance, a project in Southwark is developing a new approach to help older people who are moving from acute care, providing specialist “step down” facilities to give them time to recover from acute illness while supporting them to make decisions about their future. In this way, more older people are being enabled to return home after a spell in hospital rather than entering care homes prematurely. I think that answers a point made by the noble Baroness, Lady Eccles. That is the sort of programme that needs to be rolled out. Patients already have a choice of provider for acute services, and from the next financial year will have increasing choice when they need treatment for longer term conditions. As noble Lords will be aware, money will follow the patient, providing an incentive to providers to improve the quality of their services to attract additional patients.

The NHS will make increasing use of quality indicators measuring both clinical outcomes and patients’ perception of the quality of the services they have received. Indicators at the level of health communities will enable PCTs, in dialogue with their local populations, to determine the priorities for local quality improvement. The new regulatory regime in the Health and Social Care Bill, which we will shortly debate in this House, will give an underpinning assurance that all healthcare providers are fit for purpose and will place on commissioners a new duty of quality improvement.

However, we fully accept that there is more to do. That is why the Prime Minister invited my noble friend Lord Darzi to undertake a review of the next stages in the development of the NHS. The review team has undertaken a major exercise to listen to the views of patients, healthcare professionals, managers, professional organisations and voluntary organisations on what they see as the new priorities for quality improvement in the NHS and the obstacles to achieving them. The noble Baroness, Lady Emerton, raised important issues concerning quality control at senior level in hospitals. I know that my noble friend Lord Darzi is taking those issues on board in his review. At a more local level, each strategic health authority has set up working parties to develop locally appropriate clinical pathways, as was mentioned. At the end of its work the review team will bring together the experience from each strategic health authority and determine what further work may be needed at national level to support quality improvement. The review expects to publish its findings this summer.

A particular theme of the review will be the role of innovation and the need to ensure the rapid dissemination

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throughout the NHS of advances in clinical practice. Several noble Lords talked about the need to disseminate information. I will not pre-empt the conclusions that my noble friend will reach on this important topic but I would like to draw to the attention of your Lordships’ House the work of the Innovation Centre which we established in 2005 to ensure that innovative ideas originating in the NHS itself are effectively exploited.

I shall attempt to cover as many points made by noble Lords as I can. The noble Baroness, Lady Eccles, raised several points. Her contention—I will not say “accusation”—was that the operating framework was overly prescriptive and she challenged the increase in targets for PCTs. The 2008-09 document marks the beginning of a new chapter in the journey to transform the NHS and sets out a truly ambitious programme for the NHS over the next three years. This means that local PCTs will control more of the NHS budget than ever before, giving the organisations freedom and flexibility to spend according to the needs of local people. From next year, 82 per cent of the local NHS revenue budget will be in the hands of the front-line NHS. We expect the PCTs to work to the five national priority areas. I would be interested to know which of those areas is not regarded as important, because we regard them all as equally important. We know that is a great challenge for PCTs in determining local priorities and setting local targets to meet the needs of their communities.

The noble Baroness, Lady Eccles, talked about RiO, which is a vital strategic community information system in London. It was selected as a replacement for the existing child health system, but it is being used for considerably wider functionality. Following the start of its rollout, it is now being used in 17 PCTs. Those trusts are already deriving significant benefits, and other trusts will see those benefits. We agree with the noble Baroness that it is essential that members of staff are properly equipped, and we will write to her about the remote access issue that she raised.

The noble Baroness also raised the issue of healthcare-associated infections. She knows that action on healthcare-associated infections is a top priority for the Government. It has been made clear most recently in the NHS operating framework, at a time when we are deliberately trying to reduce the number of central priorities, that we have made this one of the priorities. The measures that have been taken are already having an effect. MRSA infections are on a significant downward trend and have dropped by a further 18 per cent since the previous quarter. For C. difficile, there was a reduction of 16 per cent in the number of cases since the same quarter last year.

Several noble Lords raised the issue of GP access, including the noble Baroness, Lady Shephard, and the noble Earl, Lord Howe. In his interim report Our NHS, Our Future, my noble friend Lord Darzi identified access to primary care as an immediate priority, especially in the more deprived areas, as the noble Earl mentioned. In addition, patient service and public discussions have consistently told us that improving access to GP services should be a priority for the NHS. It is true that a very large proportion of patients are very happy with their GP services, but it

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showed that 16 per cent of people are unhappy with the opening hours of their GP practice. That is nearly 6.5 million unsatisfied patients. This is being addressed through two major initiatives. First, in October 2007 the Secretary of State for Health announced a £250 million access fund, which will deliver at least 100 new GP practices in the 25 per cent of PCTs with the poorest provision which, as we know, are often in our poorest communities. All health centres will provide core GP services from 8 am to 8 pm seven days a week, offering both booked and walk-in services for registered and non-registered patients.

Secondly, it is our aim that at least 50 per cent of GP practices in each PCT area should offer extended opening hours on weekday evenings and weekends based on patients’ expressed views and preferences. We recently put the proposal to the BMA that would pay for an extra average three hours of work a week and, as noble Lords will know, that is progressing.

The noble Baroness, Lady Shephard, raised the issue of the closure of small hospitals and asked for a peek into the results of the work carried out by my noble friend Lord Darzi. While she will appreciate that we cannot pre-empt the conclusions of the review, we fully recognise the need to provide good access to care to all sectors of the community and we recognise the role of small hospitals. Ultimately, it is for the PCTs to decide for their local populations.

My noble friend Lord Rea raised the issue of low birth weight. It is the case, and he is right, that we in the UK need to address that. We have given a commitment in the next three years to improve the health and well-being of children.

I am aware of the issues outlined by the noble Baroness, Lady Knight, and I have read all the related correspondence. I know that she has been very concerned about this for some time. She has met the Minister, Ivan Lewis, and they have been in communication with each other. My understanding was that each case had been examined and results had been forwarded to the noble Baroness, but if there are further issues that she would like to raise, I would of course be more than happy to discuss them with her. She will be aware of our recent discussions on nutrition, which I will come on to in a moment—in fact, now.

The noble Baronesses, Lady Masham, Lady Eccles, Lady Knight and Lady Greengross, raised the issue of food in hospitals. Noble Lords will know that I spoke about this only a few weeks ago, and we fully accept the importance of ensuring that all NHS patients get the best possible food for their condition. There is no excuse at all for neglect in this area. The Better Hospital Food programme was set up in 2001 to improve hospital food. There are two aspects to this: improving the quality of the food that people eat and, when it has been improved, making sure that they get the opportunity and assistance to eat it. We hope and expect that protected meal times, when non-urgent clinical activity stops on the wards, patients are given space to eat and enjoy their meals, and staff have time to provide help for patients who need it, will make a significant impact on this issue.

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More recently the nutrition action plan, Improving Nutritional Care, was published in October last year, following two summits attended by charities, clinicians and nutrition experts. The implementation plan is being taken forward, it is chaired by Gordon Lishman of Age Concern, and I am absolutely confident that if we do not get this right and the situation does not improve, we shall certainly know about it.

My noble friend Lord Parekh talked about communications between hospitals. Most standard tests are back with GPs within 48 hours and further work is ongoing regarding the 18 weeks’ wait. Part of the point is that electronic patients’ records will allow shared records between primary and secondary care.

My noble friends Lord Parekh and Lord Rea, and one or two other noble Lords, expressed views on the National Audit Office report published today. The Government welcome the report and will consider its recommendations carefully. The GPs’ contract, as the report recognises, stems from the haemorrhaging of GPs from the NHS, and it improved quality for the public.

I am informed that I have only one minute left and there are many other things that I wish to say about targets. I am afraid that I shall have to write to noble Lords on all those matters. Perhaps I may say to the noble Lord, Lord Mancroft, that I am sorry that he had a bad time recently. It is important to let the hospital know what happened. I thank noble Lords for their contributions to the debate.

The Deputy Speaker (Lord Colwyn): My Lords, the time allotted to this debate has elapsed. Does the noble Baroness wish to withdraw her Motion?

Baroness Eccles of Moulton: My Lords, I thank everyone who has spoken in this debate and I beg leave to withdraw the Motion for Papers.

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