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30 Jun 2008 : Column 28
“The power of information will be provided to the public. We will legislate so that all providers of NHS services will be required by law to publish quality accounts just as they publish financial accounts. These will detail the quality of care that they provide for each and every service. Easy-to-understand comparative information will be made available online.
“For the first time, improvements to quality will be recognised and rewarded. Patients’ own assessments of the success of their treatment and the quality of their experiences will have a direct impact on payments. We will harness the expertise and experience of clinicians to raise standards by ensuring strong clinical involvement at every level of the NHS. New medical directors will be appointed to join existing nursing directors in every NHS region. They will be supported by clinical advisory groups to sustain and support the strong clinical voice elevated through the review.
“Nationally, a new quality board will be formed to provide leadership, to give advice to Ministers on top clinical priorities for standard setting and to make an annual report on the state of quality in England compared to international peers. There will be strong safeguards for quality, with no hiding place for those who fail to get the basics right on issues such as infection. I have already announced that the Care Quality Commission will have tough new enforcement powers to tackle infections and other lapses in patient care.
“Finally, we know that healthcare works at the edge of science, constantly creating new ways to cure and care for patients. The NHS has long been a pioneer, but too often too few NHS patients have benefited. We will create an environment where excellence and innovation can flourish. That is why this report heralds new partnerships between the NHS, universities and industry to achieve the very best care for patients. This ambitious agenda to improve quality for patients can succeed only by unlocking the talents of the front line. We will ensure that NHS staff have the freedom to focus on quality, empowering them to improve services.
“Clinicians have abilities that go beyond their clinical practice alone. Our new expectations of professionalism redefine their roles as practitioners, partners and leaders in and of the NHS. We will unlock their creativity and innovation, give greater responsibility for stewardship of resources and proclaim a new obligation to lead change where the evidence shows that it will improve quality.
“These noble objectives will be supported by pragmatic action. Our journey of setting the front line free from central direction will continue. Our commitment to foundation trusts remains strong and we will extend similar freedoms to community services. We will free up their talents by introducing a ‘right to request’ to set up a social enterprise. All primary care trusts will have an obligation to consider these requests, and staff choosing to join such organisations and continuing to care for NHS patients will be able to retain their pensions.
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“With greater freedom will come a newly enhanced accountability. The report sets no new targets. Our approach will be openness on the quality of outcomes achieved for patients, meaning accountability for the whole patient pathway from beginning to end. NHS staff are the service’s most precious asset. We will more clearly illuminate how highly we value them by making new pledges to all staff on the constitution, on work and well-being, on learning and development and on involvement and partnership. All NHS organisations will have a statutory duty to have regard to the constitution.
“Furthermore, the system for education and training will be reformed by working in partnership with the professions. We will open a new chapter in our relationship with the medical profession by establishing Medical Education England. We will increase our investment in nurse preceptorships threefold so that newly qualified nurses will be given more time to learn from their senior colleagues. We will pay a higher regard to the contribution of non-clinical staff—the porters, administrators and others who are the backbone of the service—by doubling our investment in apprenticeships and we will strengthen arrangements for learning and development so that all staff have access to the opportunities that they need to update and enhance their skills. Following today’s publication of the final NHS next-stage reviewreport, we will, over the course of this week, be publishing supporting documents setting out in more detail our conclusions for primary and community care, for workforce and for informatics.
“Let me turn to the first NHS constitution. The changes outlined by the review will improve quality, but the best of the NHS—its enduring principles and values, its defining rights and responsibilities—must be protected for generations to come. Patients and the public should be empowered by the clear expression of their rights in relation to the NHS and the value of staff should be fully recognised. Decision-making should be transparent and accountability strengthened. It is right and proper that a national health service funded by national taxation should remain accountable in and to Parliament. These goals are accomplished by our draft constitution, which we will publish for consultation today.
“Our proposal is to legislate so that all NHS bodies and independent and third sector providers of NHS services must take account of the constitution in their decisions and in their actions. The Government will be required to renew the constitution every 10 years, involving the patients who use it, the public who fund it and the staff who work in it. No Government will be able to erode or undo the fundamental basis of the NHS without the consent of the people’s elected representatives. Safe in the knowledge that the best of the NHS shall not perish, we will pursue our ambition to deliver the highest quality care to all, not in some respects, not in many respects, but in all respects. On its 60th anniversary, after a decade of investment, the NHS has the most talented array of staff in its history, united in their ambition. High quality care for all is
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My Lords, that concludes the Statement.
4.16 pm
Earl Howe: My Lords, on behalf of these Benches perhaps I may first express my thanks to the noble Lord, Lord Darzi, for having repeated this important Statement to the House. I confess that it is a slight surprise to me that, as the Minister commissioned to carry out the next-stage review and to bear prime responsibility for it, he should be repeating the Statement rather than making it on his own account. I am sure I cannot be alone in attaching some significance to that. What we all hoped would emerge above all from this exercise is the noble Lord’s own vision for the future delivery of healthcare in England with the benefit of sound advice from the professions and after the freest possible consultation. We did not want the noble Lord to be in any way hijacked. The fact that the Secretary of State should have appropriated today’s announcement to himself could be indicative of what some of us feared when we read Mr Johnson’s comment in the Guardian earlier this year when he said that he regarded the noble Lord as a tethered goat. The noble Lord deserved better than that. But it is one reason why I suggest to the House that we need to examine this review for evidence of what one might term unwanted departmental influence.
The report which the noble Lord has summarised for us today has been long awaited and will doubtless be pored over in the weeks to come by all with an interest in it. I have not yet had an opportunity to read it, and for that reason it is not possible for me to pass any detailed comment. However, there are surely two tests that the report needs to pass if it is to command acceptance and approval. We need to see that the benefits to patients that it trumpets are genuine and evidence based, and we need to see that its recommendations are achievable, given the inevitable constraints of funding, premises and the numbers of medical and other professionals on the ground.
The noble Lord spoke of this Government having resuscitated the NHS. I should like to think that if he had given this Statement himself, he would not have said that. After 11 years of a Labour Government, he will know that the backdrop to this report is a picture of health outcomes of which this country cannot be proud. For all the additional money poured into the NHS over the last few years, we still have cancer survival rates that are below the European average, high mortality rates from heart disease and stroke, and mortality rates from lung disease that are little short of abysmal. It is therefore strange that we should now suddenly be talking about needing to put quality at the heart of NHS care. The noble Lord spoke of the quality and outcomes framework, but we have seen this year how the QOF was all but neutered by politically driven objectives at the expense of the well considered recommendations of the expert group.
The noble Lord has spoken of putting patients’ wishes first and giving doctors and nurses clinical autonomy. I hope he will forgive me if I say that this
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I welcome the idea of having indicators of quality and patient satisfaction—we have advocated those—but what has become of practice-based commissioning? How do the Government view the role of foundation trusts in the future? What is to happen to payment by results and how is the tariff system to be improved and unbundled so as to remove the barriers to delivering properly costed treatments? These mechanisms were meant to be the engines for improving the quality of care in the health services, but we have heard nothing about them.
The new performance regime published four weeks ago gives strategic health authorities the power to control their areas. That did not have the ring about it of the kind of local autonomy that the noble Lord has spoken of. In his review of the east of England, the noble Lord proposed,
Can he look us in the eye and say that this is a locally driven decision? If that kind of approach is to be adopted up and down the country, can he assure us that the risks of establishing further bureaucracy will be avoided?
The Minister has spoken of removing the postcode lottery for medicines. With respect to him, we have heard this innumerable times before. Of course we will support any moves towards greater transparency of decision-making by PCTs—I proposed an amendment to the Health and Social Care Bill last week on exactly that point—but this country is still amongst the slowest to take up new medicines. If local availability of medicines has in the past been constrained by insufficient funding, how can the noble Lord suddenly be so confident that the postcode lottery will be made a thing of the past?
The noble Lord will know the worry that exists about maternity services. The Government say that they are in favour of home births, yet in recent months 15 maternity units have been closed or have lost their obstetric service and 26 more are under threat. If obstetric services are located more remotely than they were before, how can mothers-to-be safely opt for home births? What undertakings can the noble Lord give that his proposals will not lead to super-sizing of maternity units when the evidence shows that the performance of smaller maternity units is, on average, higher than that of larger ones? Here again, the noble Lord speaks of listening to local opinion, but the whole drift of recent announcements and reorganisations has been towards greater centralisation of NHS services.
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When the Minister announced the results of his review of the NHS in London, he famously declared that,
Would he like to take this opportunity to expand on that statement in the context of this review? What are the implications of today’s report for the centralisation of GP services in so-called polyclinics? We did not hear that magic word mentioned in the Statement, but the idea, surely, cannot have been abandoned. I have no objection to polyclinics; what I object to is their imposition on communities without consultation. What is the noble Lord’s view of the place of the community hospital in delivering non-acute care in the community? We have not heard anything that gives us even a flavour of how he believes services, both acute and non-acute, should ideally be reconfigured. The Statement is long on generalities but short on specifics.
The Statement referred to workforce planning, but what answers do the Government have to Sir John Tooke’s review? The MMC implementation represented a monumental blow to medical morale and there is apparently no end in sight to the pressures which gave rise to that debacle. What is the Minister’s proposal for resolving that aspect of workforce planning?
Last year the noble Lord, Lord Darzi, accepted an immense challenge when he agreed to undertake the next-stage review. Whether or not every detail of his report commands agreement among parliamentarians, he has fulfilled that challenge—and on that, he deserves our congratulations. He also deserves to have more time with his patients, which I hope he will allow himself to have. We wish him well.
The Minister knows, or should do, that my party does not indulge in opposition simply for the sake of it. We will support him and the Government whenever we think that proposals for the NHS are right and in the interests of patients. As we celebrate the diamond jubilee of the NHS, our reaction to this report is no exception to that principle. Nevertheless, the Minister’s real success or failure will be judged not by what is on the printed page of this report but by the improvement of the health and well-being of the population and the quality of care that patients receive over the years ahead.
4.25 pm
Baroness Barker: My Lords, I, too congratulate the noble Lord, Lord Darzi, on, I think I am right in saying, the first Statement he has ever given to this House and on the completion of a major piece of research. After what must seem like an interminable gestation, he has seen it successfully launched. It is an important report, a review on which, to a great extent, the hopes of patients and the NHS workforce depend.
Sixty years ago that great liberal, Beveridge, brought to fruition his vision for a health service fit for a nation going through great transitions after the War. When the noble Lord’s review was announced, one particular element within the very long terms of reference caught my eye. He set himself the task of working out how a publicly funded, comprehensive, affordable, high quality health service could be delivered on the basis of need, not the ability to pay. It is that laudable
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Like the noble Earl, Lord Howe, I have only just received a copy of the report and am not in a position to comment on it in any great detail. As the report has been heavily trailed in the press this week, however, I want to start by dealing with one issue. Ever since 1948 the NHS has been subject to review after review, all of which have attempted to do the same thing: to reconfigure staff resources and patients in order to achieve better health outcomes and to reduce health inequalities. Practically all those reviews have, in the end, come down to one of two things: either a restructuring of the management of the service or a focus on buildings. Coming as he does from a clinical background, and with the support of clinicians across the piece, I hope that the Minister will be able to avoid the trap in which healthcare is essentially evaluated on the basis of buildings.
I notice that he did not talk about polyclinics in his Statement. We on these Benches will also support them only when they are the result of local decision-making by people in areas who have the clinical and resource data to come to the conclusion that the development of a polyclinic will change for the better the health outcomes of their area.
NICE is one of the achievements of which this Government should be most proud. It is one of the most essential parts of any health service. The independence and authority of NICE should never be undermined. I hope that it will be given the resources necessary to implement the speedier approval process, while ensuring that nothing is done to compromise the levels of our research into pharmaceuticals and new medical technologies. I hope also that, whatever decision this House arrives at on co-payments, nothing will be done to compromise the integrity of diagnostic and treatment processes, so that everybody in the country will continue to have access to the highest standards of clinical judgment.
I was interested to see in the report the proposal for an NHS evidence service. We will wish to look at that in greater detail, but if it builds on the system of national service frameworks which we have had for the past 10 years, where best practice is brought together with new knowledge, and provided that it is backed up by sufficient resources, it will be an important development.
The Minister spoke about innovation and the need for us to use the NHS as power to innovate. He then spoke about staff being enabled to set up social enterprises. I am not sure that I agree with those two things going together. The NHS has been responsible in its time for some of the most marvellous innovations. Embryology, for example, has been taken forward in this country unlike in any other. I hope that the Minister in his proposals is not opening the door to increased private provision within the NHS.
I could not help but notice that there was no mention of mental health in the Minister’s Statement, nor was there much mention of long-term conditions or community care; the focus was very much on an acute care system. If noble Lords have any doubt
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The one other question to arise from the Minister’s Statement was money. How will the implementation of the review be funded? To what extent will its implementation be dependent on the sale of NHS property and land?
We welcome an NHS constitution in so far as it brings about concrete guarantees that nobody in this country will in the foreseeable future suffer health poverty. One of the most telling passages of the report on London of the noble Lord, Lord Darzi, was that in which he charted life expectancy at different stages along a Tube line. In so far as the report brings about greater health equality and reduces health poverty, it will have our support.
4.34 pm
Lord Darzi of Denham: My Lords, I am grateful to the noble Earl, Lord Howe, and the noble Baroness, Lady Barker, for their response to my Statement. I have been here for 12 months and constantly learn about protocols and rules. I have been told very firmly that there are strict protocols for Statements being made in the Commons first. The House may wish to change the rules. On this occasion, though, I reassure the noble Earl that I have led this piece of work with a team of Ministers, including my right honourable friend the Secretary of State, to whom I am very grateful for giving me all the space. It is not only me; it is important to highlight that this is not the “Darzi report” but the report of 2,000 doctors and nurses across the country, who have led this review at a local level, based on evidence and in partnership with patients and the public as a whole.
The noble Earl raised a number of important questions and issues. First, on quality, why now? As a clinician who works in the health service, I do not want to sound political, but if I take myself back to the day on which I was appointed in 1994, I can remember arriving at St Mary’s Hospital, where I was the only clinician with an interest in bowel surgery. Now I am a member of a team of four other surgeons, two nurse practitioners, one nurse consultant and two stoma nurses. It is important to remember the state of the health service back in those days and where we are at the moment.
You cannot aspire to achieve quality if you do not have the infrastructure. You cannot aspire to achieve quality without an adequate number of doctors and nurses or without the right environment in which to work. This is our opportunity to refocus what the NHS is all about. What energises me in coming to work every day is to improve the quality of care. What patients want when they see me in my clinics on a Friday or a Saturday, at the most vulnerable time in their lives, during sickness, is better-quality care. Earlier I said that quality was not just about the clinical outcomes that clinicians such as me will have an interest in; it is also to do with patient experience.
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The quality framework that I described is very detailed. We have never had anything like it before. I strongly believe that it is how we will provide the clinicians with the power that they need in improving what matters most—the quality of care. The noble Earl touched on the issue of morbidity and mortality. We have dramatically improved our outcomes and there is clear evidence of that. A recent publication by Sheila Leatherman in her joint publication with the Nuffield Trust clearly highlights this. Mortality following myocardial infarct in this country has dropped by about 42 per cent, which is the highest drop that any country in the world has seen. But I agree with the noble Earl that we can do better. It is not uniform—and the whole purpose of this report is to help clinicians at a local level.
I could not agree more on the question of targets. That is why I made an explicit statement that there will be no more targets. But let us remind ourselves that targets met the aspirations of the patients who used the service. When you double the investment in the health service, you have to have compliance measures in which you can reassure the taxpayer who is funding the system but, more importantly, the users of the service. Let us again remind ourselves that, on the day when I was appointed in 1994, there was no such thing as standards in the NHS. It was a free for all. I decided which patients came in; patients would wait for 18 months and longer and would sleep overnight on trolleys in A&E departments. We had to have targets and hold the provider end of the NHS accountable for the money that it received in relation to patient care. So the targets will become minimum standards—and, as I said in my report, there are no new targets in that report.
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