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The noble Lord, Lord Darzi, led the NHS Next Stage Review which was published last year entitled High Quality Care for All. It said that we need to move from an NHS which is rightly focused on increasing the quantity of healthcare to one which focuses on improving the quality of care. If quality is to be at the heart of everything done in the NHS, it must be understood from the perspective of patients. That is quite a change in many parts of the NHS. Patients are
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Improving the quality of service has to involve everyone. It requires a true team effort, with everyone committed and everyone proud of the achievements. The noble Lord, Lord Darzi, was right to say that change is most likely to be achieved if it is led by clinicians. I agree with that. The emphasis should be on teamwork and inclusiveness. In many hospitals, still too large a proportion of staff feel undervalued and in some—I do not say all—major hospitals senior medical staff are still viewed with awe or fear rather than as lead partners in achieving high quality outcomes and patient experience.
The NHS is a large and daunting structure for patients, and I wonder whether we do enough to integrate the patient’s needs and experience through primary, secondary and tertiary care. People often go through all those. Is enough done to take people through that on a continual basis, avoiding cancelled appointments, missing or out-of-date information, so that they have to go back again to see the consultant, and all the things that we know can go wrong?
A few years ago, I suffered from an underactive thyroid—I still do, of course—and I went to see many NHS consultants, until I found one who knew what it was, although it was not his specialisation. I had an appointment to see one chap and, as noble Lords would expect, I arrived for the 12 o’clock appointment at about three or four minutes to 12 o’clock and discovered eight people waiting. When I asked the secretary whether the specialist was on time, she said, “Yes, but you’re eighth in the queue”. Twelve o’clock did not mean 12 o’clock; it meant that that was when a group of people turned up. I had to cancel the appointment because I had a number of other things to do that were extremely important, more important than my health. I cancelled the appointment and felt very bad about that. In that little microcosm, that NHS cost itself resources and money, it did not do the patient experience any favours and left me feeling very frustrated. Nobody gained, and nobody got a grip on it.
Raising quality does not mean increasing costs or reducing productivity, far from it. In my view, raising quality is about addressing the whole process of delivering a health requirement and means finding ways to deliver more for less, provide more time to improve the patient experience, review outcomes and seek further improvements. My view, speaking with a business school background, is that the message that improving quality will cost more and reduce productivity so that we cannot afford to do it is far from the truth. We can have more for less if it is seen as a process, not in isolation. Times are going to be tough for the NHS in the next few years. There will be plenty of people saying that they cannot afford to have meetings to discuss these things because they have enough on as it is, but I believe that it can be achieved.
When I was in the United States not long ago, talking about the health industry and the role of medically qualified people, I discovered that in some
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2.54 pm
Lord Rodgers of Quarry Bank: My Lords, I greatly welcome this debate and listened to the speech of the noble Lord, Lord Walton, with pleasure and close attention. I am wholly a layman and I speak as a patient about one niche of concern. Eight years ago, I had a stroke. I was very lucky; there was no apparent physical damage, but my reading, writing, speaking and comprehension were severely affected, and I had two and a half years of speech therapy. I raised this matter in the House in a debate three years ago, and I have since had two similar opportunities to discuss stroke.
Initially, I was critical of the NHS, and particularly Health Ministers, for neglecting, over many years, the causes, consequences and treatment of stroke, which had an unacceptably low profile among major diseases. These shortcomings were set out in a devastating report by the Comptroller and Auditor General in 2005. More recently, there has been substantial progress, as the noble Lord, Lord Walton, said. The Stroke Association called its recent document Getting Better, which is just about right. I should add that I am a member of the All-Party Parliamentary Group on Stroke, which is ably chaired by Andrew Lansley MP, the Conservative health shadow who has recently been having a rather tough time.
Today, I am looking at stroke again, on this occasion in the context of the new National Sentinel Stroke Audit published by the Royal College of Physicians in April, and at the role of stroke research. I have already warned the Minister of my particular interest, and I hope she will be able to respond. In sum, I am disturbed that the new sentinel audit report shows that there remains a serious gap between what is actually happening and what should happen. There have been significant improvements. Twenty-nine per cent of patients are now admitted to a stroke unit on the same day and 57 per cent are admitted either the same day or on the following day. That is a major step forward since 2006. There have also been marked improvements in the speed of assessment by therapists after admission. All this is good.
However, the headline of the sentinel audit is that a quarter of stroke patients are still not given the best treatment. It refers to,
- “unacceptable variations in the quality of care between hospitals with some parts of the country still failing to provide anything approaching an acceptable service”.
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There is even a group of hospitals,
Professor Roger Boyle, national director for heart disease and stroke, the so-called tsar, has commented on the audit. He said:
“The national stroke strategy is a ten-year plan, and there are no simplistic quick-fixes ... But, by making stroke a number one priority for the NHS, providing extra funding and establishing the Stroke Improvement Programme and local stroke networks, we are now firmly aiming at the revolution in stroke services”.
I have great respect for Professor Boyle and admire his commitment. However, will the Minister confirm that the 10-year plan is on target, that the extra funding is in place and that it will remain undiminished with no delay or redesign, which is a familiar euphemism for setting something aside?
Within the national stroke strategy, there is yet another strategy, the stroke research network or SRN. The health department says that:
“The SRN provides a world-class health infrastructure to support clinical stroke research and remove barriers to its conduct”.
I should say that three years or so ago, I agreed to become a patient representative on the Thames Stroke Research Network and, later, played a very modest role in its launch in April 2007. I am concerned about the stroke networks and whether they have been established on time and are achieving their preliminary purpose. I should be grateful if the Minister would confirm that that is the case and that the department intends to make them a permanent feature within the continuing national stroke strategy
I have said that strokes have been the poor relation—if I may put it in an awkward way—of other diseases. This has been reflected in inadequate research funding. According to a Written Answer in the House of Commons, the aggregated expenditure on stroke research in 2006-07 was £9.87 million—a tiny sum. I find the Answer confusing, because it adds that comparable information in respect of the department’s centrally managed research programmes is not available. I ask the Minister why not, and, in particular, where can I find the costs of the Stroke Research Network?
I come briefly to the current outlook, taking into account the national financial and debt crisis and the prospects for public spending, especially on health and health research. In a long political life I have become familiar with such crises, to which I have been uncomfortably close. Ministers of the day have admitted the quantum of lower expenditure, but tried to hide the damage. They have concealed the consequences by discreetly scaling down plans, delaying capital investment and using expenditure figures in cash rather than real terms. They have talked about huge sums in unspecified efficiency savings, making everything stronger, leaner and fitter. However, I am afraid that much of what has been called painless has been cuts by stealth.
Until a few weeks ago, there was a remarkable silence about public expenditure cuts beyond 2011. The King’s Fund says that the NHS could face drastic cuts as the service moves from years of significant growth in its real terms funding to very low, zero or negative growth. Will the Minister say in plain terms whether the Government agree with the King’s Fund
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3.02 pm
Lord Mawson: My Lords, it is a privilege to share this debate with my noble friend Lord Walton. I begin my contribution to the debate on the future of the NHS by addressing my remarks to the opportunities presented by social enterprise for the future of health and, in particular, primary care.
In recent months, many of us have listened with growing concern to the unfolding story of Baby Peter in Haringey—one of the tragedies that point to the lack of joined-up working between health and social care services and to an insufficient focus on people. Despite years of talk about joined-up working and putting people first, this is still very patchy in practice. While we have moved some way down the road to co-locating services in primary care buildings and to recognising the role of social entrepreneurs in health, we still have a way to go in making greater use of community and integrated approaches to health and in using the talents and ingenuity of local people.
I was interested to hear my noble friend Lord Laming, in a Radio 4 interview, describing how difficult it was for Ministers to get the words about joining up health and social care off the pages of glossy reports and into reality on the streets of our towns and cities before yet another crisis erupts on to our television screens. I suggest that putting people before structures is the only practical way of joining up services and implementing a truly integrated approach to primary healthcare in this country. We need to use the innovative skills of social entrepreneurs and organisations that have a proven track record and to back such people by giving them the resources and freedoms that they need to transform the health and well-being of the communities that they serve.
Many of these people are doctors—I have worked with some of them. Many others are individuals working in third sector organisations and leading teams of dedicated people committed to improving health and social care services in their local communities. These people seldom appear on the NHS radar and, even when they do, are rarely valued for the contribution that they make. The tragedy is that despite the years of commitment to new commissioning structures—third sector compacts, social enterprise initiatives and the like—there is still little widespread procurement of local holistic services from social enterprises or the third sector. The true meaning of “third sector procurement” seems to be in the name itself. Successful third sector organisations and social enterprises often feel that they are the third choice—that the bits that the public sector might not want to deliver get passed down the line. Second in line is the private commercial sector and, finally, at the end of the queue, we have the third sector patiently waiting its turn for the crumbs from the table.
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The poor souls in the third sector are no third-rate choice. The third sector is like any other sector—better in some places than others. Our approach to procuring health and social care services is ignoring some of the most talented and innovative individuals and organisations—people who have been working tirelessly in their communities for far longer than the perennially reconstituted PCTs and health authorities.
This is my experience over 25 years in Bromley-by-Bow in east London. Over the years, rhetoric around the holistic integrated model has never been matched by an integrated commissioning structure that delivers a Bromley-by-Bow-style approach to public service delivery, community regeneration and social enterprise.
I am afraid that I see little room for optimism in the latest polyclinic initiatives. The noble Lord, Lord Darzi, and his team have produced a programme for primary care that will produce wonderful new buildings and a new level of integration that has never been seen before. However, I have a profound problem with the scheme. At its heart it is still a biomedical model of healthcare that focuses on delivering clinical interventions for patients. Important as this is, it is only one dimension of a multidimensional problem. We are building not polyclinics but monoclinics.
I am sure that the Department of Health recognises the multicausal nature of chronic ill health in our communities. However, after all these years of rhetoric, we still seem unable in this country to create commissioning structures that cut across the departmental silos of government and focus on the customer. Why should that be? In my view, there is a problem at the core of our understanding of integration. Many in the public sector still think that this is about only traditional bits of the public services working more closely together.
We need holistic approaches to public service delivery that use social enterprises to deliver better services and better value for money across a range of measures. Where better to start this approach than in primary care? These solutions are particularly relevant today when the financing of the medical intervention model has been put under severe strain as a result of the financial crisis. However, I fear that despite the rhetoric the Government—and perhaps a future Government—still do not understand how practically to use entrepreneurs in the delivery of health services. I know that it works because in the past few years I have had the privilege of seeing and working with such entrepreneurial health organisations across the country. These organisations put people first because they understand and are part of their communities. They bring together health and social programmes. They are trusted, not because they engage in elaborate consultations but because they have a track record of delivering services that local people need.
There is of course no shortage of action by the Government. A multiplicity of programmes for the provision of integrated health services by the public, private and social enterprise sectors has been initiated. My concern as I travel across the country is that these initiatives, while well intentioned, by and large do not rely on the ingenuity and talent of entrepreneurs and local people but continue to use the old bureaucratic and paper-based mechanisms. Bureaucracies like talking to bureaucracies and doing many of the same old
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As I have listened to debates in your Lordships’ House in recent months, Ministers, including the noble Lord, Lord Mandelson, have highlighted in public conferences the virtues of social enterprise. Yet in the health sector basic conversations are still not taking place. I have spent the past five months since the publication of our report on social enterprise and health—here I must declare an interest—attempting to bring Ministers to the same table as colleagues from NHS LIFT and the Big Lottery Fund in order to bring new joined-up investments to support an integrated approach to health.
What the Government have done to date is commendable, but the NHS now needs to change its paradigm from the expensive clinical model to one based on networks and more modest-scale and sustainable initiatives that can be private, public or social enterprise—it does not matter. What matters is that entrepreneurial leadership and organisational culture put people, not systems, first.
If this Government—or a future Government—are serious about the future of the NHS and about social enterprise and community cohesion, I humbly suggest that a first step might be to do the following. First, they should ensure that their programmes are led by individuals with a strong track record of enterprise and appropriate risk-taking, as well as delivering innovation in mid-sized organisations. These should be people who understand the challenges of growth businesses; this is a job not for academic civil servants but for social entrepreneurs. Secondly, the Government must stop being fixated on new health initiatives and focus on making sure that the basic framework is in place to support communities in the delivery of their health services. Thirdly, they should move from a generalised support for social entrepreneurs to an informed support, which understands in detail how an entrepreneurial approach helps to deliver efficient services in the health sector. As always, the devil is in the practical details. Fourthly, they must start to assess health interventions not through reports and targets but through a focus on the health of patients and their care. Too often you get what you inspect and not what you expect. Fifthly, we need to ensure that all procurement opportunities by the Government are open to social enterprises and that procurement is not biased against small organisations. This applies very clearly to the procurement for GP surgeries under the APMS arrangement. Finally, we need to ensure that different interventions by the Government and actors talk to each other. This is not happening at a very basic level across the country. This is the road to enterprising healthcare and social cohesion.
3.12 pm
Lord Turnberg: My Lords, I, too, congratulate the noble Lord, Lord Walton, on introducing this important debate in such a characteristically lucid way. No one
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I focus my remarks on two topics that are seen to be major inhibitors of research in the UK. First, there are the difficulties posed by the multitude of regulatory bodies that have to be satisfied before research can go ahead. Secondly, there are the hurdles that have to be jumped before research can be done not on the patients themselves but on information and data about them.
I return to the subject of regulation. Despite valiant attempts at bureaucracy-busting by many, including my noble friend Lord Warner when he was the Minister, researchers are still faced with a rising tide of form-filling required by innumerable bodies that seem to take for ever to respond. A recently appointed lecturer, funded by the new and welcome investment from government and charities, will often spend the whole of his or her first 12 months waiting for approval to do the research that they were appointed to do. What a terrible waste of time and money. The pharmaceutical industry is also looking to other countries in which to do its research because of the long delay before it can get approval here.
No one denies the need for careful and thorough regulation of research on patients—certainly not the researchers themselves. They gain funding through a rigorous peer review, against considerable competition. They have to gain the approval of the Research Ethics Committee, which is entirely appropriate and necessary. Yet sometimes they have to go through several ethics committees if patients come from different trust areas. We can run into problems where different ethics committees come to different conclusions on whether they should approve the same research. There is a bit of a postcode lottery.
Yet it is the multitude of other bodies that need satisfying where the main difficulties arise. We have the local trust R&D committee, the Medicines and Healthcare Products Regulatory Agency, the Human Tissue Authority—where tissues are to be used—and several other bodies depending on what type of research is proposed. All require their own forms to be filled in, which are often long—up to 80 pages for some—and they all have different timeframes and dates at which they will consider submissions.
Paul Stewart, a distinguished researcher in Birmingham, writes that the current bureaucracy placed on investigators,
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This is no way for the UK to keep up with the competition. Our patients, the ultimate beneficiaries, deserve better. I am afraid that I have asked this before, but will the Minister have another go at bureaucracy-busting and rationalise the number of different bodies involved in this confusing array of regulators?
Secondly, there is the need to do research not directly on patients themselves but on information or data that already exist about them in the NHS. The NHS is an enormously valuable repository of information about patients, their diagnoses, treatments, cure rates, causes of death and so on. It is the envy of the world in the completeness of its information about the whole population. It provides an extremely fertile resource for research. The problem lies in trying to balance the need to carry out that research with preserving patients’ confidentiality and trust. Questions of data protection and definitions of what constitutes informed consent or anonymisation—a horrible word—remain difficult to resolve.
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