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As someone who has been involved as a non-executive director in the health service over innumerable reforms, I wondered initially where everything had gone so
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One great thing about this House is that we have the opportunity to hear personal experiences. I have been enormously moved by the contributions of the noble Baroness, Lady Campbell, who it is so good to see here, and the noble Baroness, Lady Masham. I appreciated that there was great concern over the care of Lady Darcy de Knayth, and we are all dreadfully sorry that she is not with us still and that she had such a traumatic time towards the end. Of course, none of us can be thankful in any way for the sort of care that she received from the health service. By the sounds of things, I do not think that the noble Baroness, Lady Masham, herself has had a great experience.
From the remarks of the noble Baroness, Lady Campbell, she has obviously accessed one of the good units, which has provided the care that has ensured that we have the benefit of her thoughts and wisdom in this House. We are very grateful for that. We have had two cracking speeches from the noble Baronesses and of course one from the noble Lord, Lord Crisp, who has enormous experience of the health service. He is probably responsible for all those horrible targets and management-speak, which we all love so much, which had some influence on the NHS while he was part of it, and which he left as his legacy.
Turning to the main thrust of the matter, perhaps being involved with the hospital service in central London, I see this problem from a slightly different end of the telescope. The specialist hospitals and specialist units are almost invariably either in, or close to, acute services, and specialists across the spectrum are more often than not familiar with nearby hospitals or accustomed to attending the specialist units within their own. In any event, they are in a position to give advice on patients who are known to them. However, I accept that that may not be the situation in other parts of London, outer London or in the rest of the country. Even if a specialist unit or hospital is isolated, it should have access one way or another to the additional specialties that may be required for any patient who comes to it for care. On the other side of the coin, acute trusts should be in a position to access easily the specialist services that are required for particular patients so that there is flexibility within the way that care is provided.
I have certainly read the document HighQuality Care For All—would I have dared not to have done?—produced by the Minister and it seems clear that the general thrust of the Government's future ideal for the health service is to establish more specialist centres for major trauma, heart attack and stroke. But those will, of necessity, be for acute care, and it will be for the Minister in replying to tell us whether those with chronic or long-term disease treated in them will have after-care access to the specialists who treated them in the acute phase. That is very much along the lines of
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However, those who already have long-term conditions and are under the care of specialists, as noble Lords have said, often develop other critical illnesses. If they do become ill with a complication of their underlying disease, or one that is unrelated, what access do they have to the physicians who have been looking after them or to their records to enable them to be properly assessed on both their acute and long-term conditions, as well as to the facilities that can support them?
The new, still incomplete NHS computer systems, which were partly to ensure ready access to records, are even now not able to achieve that. There is another question of when there will be a seamless transition to paperless records that can be accessed by any clinician on any patient wherever they may present. Perhaps the Minister can tell us whether we are likely to see that completed this century.
There is also the question of whether GPs are able to get a rapid update of the patient’s most recent condition prior to the crisis described by the noble Baroness, Lady Finlay, so that accurate diagnosis and treatment can be swiftly undertaken on the basis of the history as well as the immediate crisis. Clearly, if the information had been there, it would have been vitally important in Davina’s case. The commissioning that GPs undertake gives confidence to any acute or specialist unit that the patient is supported by them.
The noble Baroness has really made a plea for there to be flexibility in the system. That was also contained in the other speeches. Such flexibility enables specialists who know the patient to be called in to give advice and bring knowledge of the history of the patient to those who have had to assume care for them under different circumstances. Clearly, that is a sensible proposal that would work as long as the unit to which the patient has been admitted is close to the consultant or GP’s base. There is already concern about the practicality in terms of time rather than commitment of hospital consultants attending too many specialist clinics in the community. The implications of travelling some distance to provide advice on a patient’s care would have to be factored into a normal routine. It was helpful to hear from the noble Lord, Lord Crisp, that there are units where telephone consultations are normal.
I suspect that we would all agree that the NHS should provide optimal care to all its patients. Sixty years on, that is a modest ambition. The Minister's proposals for the future incorporate an ideal of high-quality care, a point made by the noble Lord, Lord Crisp. It has always struck me as odd that one of the main indicators for quality is mortality rates. Most patients expect to survive an encounter with the health service, but they also want it to provide them with care that is sensitive, compassionate, expert and, as far as possible, successful. Perhaps within that could be encompassed the kind of personal attention for which the Minister and other noble Lords here today are looking. Perhaps the quality marker suggested by the noble Lord, Lord Crisp, is one that the Minister might like to consider.
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8.25 pm
The Parliamentary Under-Secretary of State, Department of Health (Lord Darzi of Denham): My Lords, I thank the noble Baroness, Lady Finlay, for calling this debate today. The issue that she raises is of significant importance to all who are treated and work in our specialist units. I will first declare an interest. Besides being a Minister, as most noble Lords will be aware, I happen to work as a surgeon at Imperial College Healthcare NHS Trust, where the noble Baroness did her training, and where the noble Baroness, Lady Hanham, happened to be chairman.
However, I should declare another interest. The noble Baroness, Lady Barker, spoke about what you could learn from portering. I know that she is right because eight years ago I had the opportunity to become a porter. You pick up many things if you see care delivered through the eyes of the porter, but I suspect that we are all here today to see how care is delivered through the eyes of the patient. My other interest to declare is that for the past two years I have been working in a specialist hospital, the Royal Marsden Hospital NHS Foundation Trust, on a two-day basis. Most would agree that that is a world-class cancer centre and one of many specialist hospitals within the United Kingdom. I am sure that I speak for all in the House when I pay tribute to our specialist hospitals and their dedicated staff who provide world-class care to many patients each year.
As I know from my own clinical practice, our specialist units can function as effectively as they do only because of the services and support provided by our acute general hospitals. In partnership, they ensure that patients receive the right treatments in the right settings at the right time. We should aspire consistently to deliver high-quality integrated care that transcends organisational and administrative boundaries. That is what matters to patients and that is why I welcome the noble Baroness’s inquiry and some of the issues that were reinforced by the noble Baroness, Lady Hanham, as the best way for integration of services to occur.
Any patient under the care of a specialist unit may experience a clinical deterioration, which may or may not be associated with their underlying condition. Let me describe a pathway of care for such patients. First, it is reassuring to know that in many cases patients can directly access the specialist team looking after them. Many specialist centres already have mechanisms that enable patients to do that, including 24-hour telephone lines, named specialist nurses and the opportunity simply to attend the ward themselves at any time. However, those patients will, on occasions, rightly attend their local general hospital to seek care. I am aware of fears that in such an event, a general unit may not have sufficient knowledge of the patient’s underlying specialist condition to provide them with the care that they require, but as with many issues in the health service, it is sound clinical judgment, and high standards of inter-professional communication and collaboration that are the key to high-quality care.
The noble Baroness alluded to the GMC guidance on good medical practice, which makes it clear that decisions on the most appropriate place of treatment for patients with complex needs are matters of professional
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In some instances, patients will have developed a direct complication of their specialist condition, such as the blockage of a shunt in a neurosurgical patient. In this instance the most appropriate course of action is a transfer to a specialist unit, and many units have protocols to ensure that this happens in a safe, effective and timely manner. On other occasions, patients may present to the general hospital with a problem that is unrelated to the specialist condition. In this instance, transfer to a specialist centre is not only inappropriate but may be harmful to a patient whose clinical needs have changed. In this scenario, the patient will remain at the acute general hospital and the clinicians caring for them may notify the specialist unit of this complication to ensure good continuity of care.
If a patient is admitted to an acute general hospital with profound physical or mental needs as a result of their specialist condition, then we would expect trusts to put in place special arrangements to care for them. These may include increasing the amount of nursing expertise available to that patient, or ensuring that the correct equipment is present and functional within the trust.
As your Lordships can see, some patients have clinical requirements that may straddle the services provided by the general acute hospital and the specialist sectors. We recognise that patients want organisations to work together seamlessly across the whole of the NHS, and that organisational boundaries should never be an excuse for poor quality care. We can and will do more to ensure integration of care, as I described in the final report of the next stage review, High Quality Care for All. It sought to address many of the issues that this topic raises, specifically the delivery of high quality care and how we can ensure that services are integrated, personal and convenient.
We will measure the quality of care provided more than ever before, focusing on the quality of care from the patient’s perspective. We will enable commissioners of both local and specialist services to work together to ensure that the necessary networks of care are available to these patients. These measures, combined with the right to choice for which we shall legislate, will continue to raise the standards of care that we provide, regardless of clinical setting, to truly world-class levels.
The noble Baroness, Lady Masham, raised the circumstances of the late Lady Darcy de Knayth. It would be inappropriate for me as a clinician to comment on that. Suffice it to say that I extend my personal sympathy to her family. She was a much respected Member of this House whose input to debates such as this one will be sadly missed.
I have a few minutes in which to address some of our more detailed discussions. The noble Baroness, Lady Finlay, mentioned the constitution and eloquently highlighted some of the values and pledges that it contains. It is a consultation document. I urge noble Lords to participate in this consultation and to strengthen this document before it comes to the House early next year, as I understand it, as a Bill.
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In chapter 4 of the next stage review, High Quality Care for All, I described in detail the quality framework that we have put together. First we defined what quality means, and within that definition of guidelines and standards we have certainly highlighted the needs of more specialist providers within the healthcare system. We have also described measures. I strongly believe that the measures which we are suggesting the professional teams should put together should measure not only outcomes, as the noble Baroness, Lady Hanham, mentioned, but the patient experience. Over the next decade we will be moving into an era in the NHS when there should be a higher regard for the patient experience than there was in the past.
We have gone even further, as those measures will be transparent and published. Patients in the future will be able to exercise choice—an informed choice rather than the choice that exists at present. Not only that, we are rewarding for quality. We suggest that from April 2009 every NHS provider will publish and be rewarded for reporting these quality measures. A year later, they will be rewarded for quality outcomes.
The moving speech of the noble Baroness, Lady Campbell, highlighted the importance of innovation and brought to our attention the fact that specialist hospitals have historically been the ones to pool innovation. This creative leadership at a local level has been highlighted at most specialist hospitals across the country. However, innovation should be the business of everyone who works in and delivers the NHS. Accordingly, in the NHS next stage review we will be mandating that strategic health authorities should make innovation a part of everyone’s business, while at the same time making available £150 million of funding for creative clinicians who wish to introduce innovations into their clinical practice. I could not agree more that quality, as I have said before, is a moving target. We should be constantly exploiting the technological innovations that we see daily and be much more proactive in introducing innovation into our clinical practice.
The noble Lord, Lord Crisp, raised points about integrating care and asked for my views on tailoring care more to the needs of the patient. The process of the next stage review probably taught us one of the most important lessons that we have learnt over the past 12 months—that change and innovation can happen only at the local level. For the first time, we engaged nearly 2,000 clinicians across the country at a local level. Through clinical leadership and the use of the evidence base, we challenged clinical working groups based on pathways of care, as eloquently raised by the noble Baroness, Lady Barker. We should stop talking about quantity and look at models of care through the patient’s eyes, starting from birth and finishing with the end-of-life pathway.
There has been the process of bringing different groups from different organisational models of delivery—primary care, secondary care, tertiary care, healthcare, social care—putting them around a table and challenging them on the best models of care, based on evidence, through which we provide high-quality integrated care, the fruits of which we have seen through the 10 regional reports. The challenge to us now is how we
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At the same time, we have announced in the primary and community strategy the pilots of so-called integrated care organisations, through which we can combine, or at least have the right incentives for, more horizontal and vertical integration, which I have no doubt will have a role to play in the future.
The noble Baroness, Lady Masham, talked about bed availability in specialist trusts. The latest figures that I have are for 2006-07, when the average bed occupancy for the NHS as a whole was about 84.5 per cent. Out of the 20 specialist hospital trusts, rather than units, for which I have the figures, in England, 16 had an average bed occupancy rate lower than that. It ranges from the lowest, the Royal Orthopaedic Hospital NHS Foundation Trust, which had a bed occupancy rate of 64.9 per cent, to the highest, the Queen Victoria Hospital NHS Foundation Trust, which had an occupancy rate of 95.3 per cent. On average, specialist hospital bed occupancy rates are much better than the national average. I do not believe that it is a capacity issue, but a co-ordination issue, as was highlighted earlier.
Baroness Masham of Ilton: My Lords, I forgot to mention the importance of children and specialist units. I hear that Great Ormond Street has a waiting list, and it is a specialist hospital.
Lord Darzi of Denham: My Lords, I am grateful, and I agree. Great Ormond Street is one of the jewels in the crown when it comes to the provision of healthcare to children in hospital. We had the opportunity this morning to talk to the chief executive, Jane Collins, who is also a doctor, about the protocols in relation to the transfer of patients. Some noble Lords will be aware that 50 per cent of patients treated in Great Ormond Street Hospital come from outside London. It has some very detailed design of pathways and advice for patients once they leave hospital on how to contact Great Ormond Street. It is the most streamlined, patient-friendly and patient-centred service. We can learn more from it and disseminate that across the country.
The noble Baroness, Lady Barker, raised a few points, including portering, which I have addressed. I could not agree more about the use of technology as an enabler in taking away some of the boundaries that exist between organisations and institutions. For some reason, it seems that we have successfully implemented that in the neurosurgical discipline, where head injuries are transferred between organisations based on CT scans. We are seeing more examples of assistive technologies in the community, in managing patients with heart failure, among others, and caring for patients in their home environment.
I also highlight the importance of the ambulance service and how we can equip them with the right technologies. They have managed the tremendous success story in London, in transferring nearly 70 per cent of patients with myocardial infarct to the right place at the right time, into centres providing 24/7 acute angioplasty
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On the points raised by the noble Baroness, Lady Hanham, yes, the 10 regional reports highlight that each region has taken the evidence base and has set very challenging and ambitious plans in setting up some specialist services, such as trauma centres and stroke centres. I have no doubt that local ownership of the visions, with the enabling report that we have given, and transparency based on quality, will have a significant impact in making that happen.
I thank noble Lords for an excellent—
Baroness Hanham: My Lords, I asked whether the units were acute care only or whether they would provide long-term care. Perhaps the Minister will address that.
Lord Darzi of Denham: My Lords, obviously trauma and stroke services are acute units. However, all 10 regional reports have some ambitious plans for patients with long-term conditions, which might be chronic illnesses; we all know that we have 17 million patients in England alone with long-term conditions. I came
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Our specialist hospitals and units provide some of the most pioneering work in the world, as I said, and are rightly treasured by the public. However, they cannot provide all the care for all the patients required at all times; nor would it be appropriate for them to do so. We all agree that, regardless of the clinical setting, quality must be at the heart of the NHS and it should be everyone’s business. High-quality care for all is our objective, and we will be unrelenting in our drive to achieve it.
- House adjourned at 8.45 pm.
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