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We are approaching a difficult time for public expenditure for whoever is in government, with high expenditure on debt interest, falling tax revenues and higher recession-driven transfer payments. Now is the time for the critical friends of the NHS to push for a bit of action on its flabbier parts, a kind of anti-obesity campaign with the NHS management of services. I start with another item from Mr Nicholson’s annual report on page 40. He says:

“While the NHS has had a good year, can we say we have done our best when 25 per cent of patients in hospital beds don’t need to be there and could be looked after by NHS staff at home?”.

It seemed to me, when I read it, a rather good question to which we need some answers before pouring too much extra cash into the NHS coffers.

Let me offer a few suggestions in my final remarks. The key to driving productivity and efficiency is for there to be a huge improvement in the quality of commissioning by concentrating the activities in a

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much smaller number of larger, more competent, bodies. It would also help to streamline the processes for changing unsustainable, often unnecessary, and sometimes downright dangerous, local hospital services. Simply buying more of the 35 per cent of spend that currently goes on fixed-price tariff items in local hospitals keeps services in those hospitals unnecessarily and will not remove unnecessary beds.

We have to drive the provision of healthcare outside acute hospital beds, more in line, I suggest, with the rather neglected 2006 White Paper, Our Health, Our Care, Our Say, which was based on a massive consultation with the public. Consolidation of specialist acute services, especially with the final stage of the European working time directive, which has already been referred to, is essential if we are to make services safe and effective for patients. I notice that my noble friend Lady Wall will be speaking. We need look no further than north London to see a large area with too many hospital services on too many sites consuming NHS resources that should be used for other health purposes.

I share the views of the Health Select Committee’s strong reservations about primary care trust commissioners. I remain unconvinced by the Government’s response to that report on this issue. It is not possible, or even, I would suggest, worth the effort, to try to produce 150 world-class commissioning PCTs. We simply will not get to the end of that journey.

To reduce our dependence on inappropriate hospital services, we have to improve significantly primary care and community services. From some of the work I initiated in London, I suggest a hefty dose of performance management and market testing on primary care trust community services. It could produce something in excess of a 25 per cent efficiency gain over time. The management of these services needs to be scaled up and improved, integrated better with GPs, social care and other services—as the noble Lord, Lord Walton, said—and far more effectively managed. I suggest that that could be done by using greater competition and new entrants to local markets. Personally, I do not care whether those new entrants come from the public sector, the private sector or from social entrepreneurs. I strongly suggest that the public do not care that much, either.

This approach is more likely to deliver the kinds of changes that the noble Lord, Lord Mawson, and others are looking for. I could mention other cases—pathology services come to mind, as do the management of estates, facilities and buildings in the NHS. The NHS has a footprint that is too big for the services it needs to provide. All these areas need to be looked at.

I end on this note. If we do not start to tackle these issues more energetically, as the NHS chief executive seems to be suggesting, it will be difficult to strengthen those areas that we probably all know need to be strengthened, such as the new dementia strategy, end-of-life care and adult social care. They have not had anything like the generosity of funding that exists in the NHS. All these Cinderella areas will be neglected if we do not tackle the issue of resources going unnecessarily into the acute hospital sector. I wish to finish with a quote from President Obama’s Chief of Staff. He said,

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3.51 pm

Baroness Masham of Ilton: My Lords, I thank my noble friend Lord Walton of Detchant for introducing this important debate. But it is the patients who come top of my list of priorities, and their safety should be foremost.

Good quality of care, the correct diagnosis and safety at all times while in hospital are what all patients desire, and they need the same quality when they rely on their care being given in the community. First-class medical training is vital, and with many complicated conditions specialised training is essential. When the specialised units are linked with universities, this enables research to expand. There should be good communication and co-operation between the universities and hospitals.

A cousin of mine, Dr Tim Inglis, became frustrated when he found that this was not happening. He did not have enough time and freedom in the UK to do his clinical research for improving patient treatment. He is a microbiologist and is now working in Australia. He has undertaken interesting research and enjoys life. It is so important that we do not lose too many of our dedicated clinical researchers.

The noble Earl, Lord Howe, and I opposed the closure of community health councils. The Government, instead of building on them, set up the health forums in their place as a patient voice and support, only to close them down after two years. The Government then set up LINks, and this is the current situation. I quote from what they have said to me in an e-mail:

“Many of us have made supreme efforts to make the new LINks model work. LINks are now 14 months old and many have managed little at all of active oversight of health and social care. They have become bogged down in processes rather than outcomes and the so-called support from the Government has been passed from pillar to post, adding to the confusion and demoralisation. Events at Stafford have since come to light and there is real concern that other Staffords out there will go unnoticed in the current situation”.

I declare an interest as a vice-president of the Patients Association, which has been supporting the friends and relatives of the 1,200 people who may have died as a result of the poor care at the Mid Staffordshire hospital. Like many others, the association has been asking for a public inquiry.

Senior doctors who speak out against dangerous practices are being frustrated, or even bullied into silence, according to new research by the British Medical Association. Doctors and nurses claim that the current law is inadequate, and that whistleblowers need much greater legal protection if they are to prevent another patient safety disaster. An NHS trust has been accused of victimising an eminent paediatrician, who claimed that a baby’s death and at least 28 botched operations on children were caused by unskilled doctors. The consultant’s concerns were ignored by hospital chiefs—who then suspended him, saying they were concerned about the state of his mental health. However, his colleagues at the University Hospital in North Staffordshire say that the surgeon—a former adviser to the Healthcare Commission—was suspended for blowing the whistle over children’s safety. There must be better protection for patients, and for these people, who try to protect them from unsafe practices. I

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should be grateful to hear a response from the Minister. Or would she agree that there should now be a public inquiry into all hospitals in Staffordshire?

I must mention a very serious problem, which is the increase in the number of antibiotics becoming resistant to infections. There is an urgent need for new antibiotics—we have become reliant on them, and we do not want the infections to win. There is a desperate need for research and development on new antibiotics, which the Government may have to take the lead on. Could there be legislation to encourage investment for the pharmaceutical industry? This is beginning to happen in the USA—could the Government set up a working group to help this to happen here? It will be a disaster for future generations if they are without antibiotics.

A strong message came out of a seminar on diabetes that I attended last Thursday, with many experts present—that specialist nurses are an essential part of the best treatment and follow-up for patients with diabetes. One consultant from Ipswich had lost his specialist nurse, to his and his patients’ dismay. Specialist nurses are also as valuable a part of a team for treatment of stroke patients, as are physiotherapists and occupational therapists. Also the specialist nurses are so important for patients with epilepsy, dermatological problems, Parkinson’s disease, cancers and many more. They are an investment—not only do they support patients in hospital and the community, they teach other nurses and junior doctors, who so often do not understand the treatments of such patients.

Dehydration in ill and elderly patients is putting them at risk when they come into hospital, and so often one hears of neglect of these vulnerable patients. If one watches hospitals at five o’clock on a Friday evening, one will see staff pouring out of the doors. Over the weekends, patients are left with only essential staff, and little goes on. If only hospitals could keep fully working for seven days a week, so much more could be achieved, and patients would not be put at risk by getting dehydrated, if they cannot drink unaided. This can also be a problem in care homes, when residents are fearful they will be scolded by staff if they drink and then have to go to the lavatory. So they restrict their fluid intake, making them dehydrated, and that makes them confused and unwell. This area needs more research and guidelines. Perhaps this is something that CQC members could check in both hospitals and care homes so that patients and residents are kept contented and safe.

4 pm

Baroness Wall of New Barnet: My Lords, I, too, thank the noble Lord, Lord Walton, for the opportunity to take part in this very important and wide-ranging debate. Like other noble Lords, I pay tribute to his career, which, when you listen to it being described, is astounding.

I declare an interest as chair of Barnet and Chase Farm Hospitals NHS Trust, which delivers healthcare across north London. I think that I am grateful to my noble friend Lord Warner for mentioning me and my contribution to the debate. He is always thought-provoking and controversial but very often right.

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The NHS is a huge organisation with many facets and it is charged with maintaining the health of the nation—a huge responsibility. It is an organisation that is continually changing and adapting to new challenges. These range from new exciting treatments to the way in which healthcare is delivered, ensuring that the focus is on the patient, as referred to by my noble friend Lord Woolmer. Innovations such as same-day or short-stay surgery, minimally invasive surgery and major developments in the treatment of cancer have all come from the service’s ability to learn from research and experience and from feedback from the patients and their families and our staff.

My trust is a partner member of the NHS Institute for Innovation and Improvement and is actively engaging that organisation in a range of development initiatives aimed at improving patient care, such as the Productive Ward programme, Lean thinking, No Delays Achiever, patient safety and the Delivering Quality and Value strategy—all things that I think we would applaud.

An acute trust such as Barnet and Chase Farm has a major responsibility for providing safe and timely care to our patients. This is rigorously monitored to maximise the efficiency of the organisation in terms of access by patients into the system and I am pleased to say that the patient experience and the quality of care are increasingly being monitored. I say that I am pleased because that is exactly why we are there. The whole range of clinical governance tools are employed to do this, but listening to what patients and their families tell us is crucial to the ability of the organisation to learn from this experience.

The national patient survey feeds us with important information on how our service is viewed by patients. Their views may be very subjective, but we have to remember that their perception of the service is vital to our understanding and our ability to make changes to improve their experience. This, of course, may be in the form of a complaint, to which our organisation pays utmost attention—it views the whole process as a learning experience. Much work goes into training our staff in the handling of criticism and using that knowledge to improve our service.

In my view, one of the health service’s huge strengths is its total commitment to training and education. The term “lifelong learning” is embraced within the service for all grades of staff in both clinical and non-clinical areas. Through the process of appraisal, the potential of our workforce is identified and nurtured to the benefit of the service and of those who receive our services. There is a well used phrase—that our staff are our most important asset—and we should not dismiss that easily.

It also has to be remembered that the service trains the vast majority of staff who go on to work in the private sector and in many other settings both at home and abroad. It should be recognised that training goes on in virtually all healthcare settings and not just in teaching hospitals, although sometimes general hospitals worry that that may be the message that goes out. The challenge and debate that that brings to individual departments are very healthy in that they introduce innovation and change to enable the service to be fit for purpose. Training also develops the trainers in

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such a way that they examine their knowledge and practice regularly and keep abreast of modern developments.

Research and development has a key role in the service. Since the early 1990s, money has been identified within the NHS budget to foster and promote research. The Culyer report in 1994, to which the noble Lord, Lord Walton, referred, paved the way for research to become embedded in most NHS trusts, including my own, which is a necessary tool for the service to develop.

The nature of research in our organisation spans all disciplines, with some focusing directly and immediately on the delivery of healthcare. This system has recently been superseded by a network system of research-active organisations. They will promote the links between primary and secondary healthcare, along with academic institutions.

My trust plays an active part in our local network; indeed, it receives an income in recognition of the research activity undertaken, which helps to support the process and develop the culture of research. As I said when referring to education, research raises the quality of an organisation, enabling a culture that embraces change and innovation, which can only benefit the future of healthcare.

My noble friend Lord Warner will not necessarily agree with this, but the local hospital is an essential component of the local community. In my area of north London, which is populated by many cultures, religions and economic groups, it plays an important role. The equitable access to our service for all has a large influence on communities living together. We must now work hard to ensure that the services that patients need are the services that they get. We will continue working with local clinicians, residents, our patients and other partners to ensure that all improvements to local healthcare are sustainable, delivered smoothly and effectively and in the best interests of all patients.

In conclusion, the NHS is an overarching organisation that continually learns from its experience and its research to deliver the safe and appropriate care for which it was created.

4.07 pm

Lord Maginnis of Drumglass: My Lords, I am grateful to the noble Lord, Lord Walton, for initiating this debate and to be able to contribute, albeit with a great deal less knowledge than he has but with equal concern that, despite the relentless march and associated benefits of modern technology, healthcare delivery and social enterprise and cohesion are not as sophisticated or effective as they could be or should be.

Over the past year or thereabouts, I have had the privilege to chair an independent review of autism services for the Department of Health in Northern Ireland. My review team found that, despite a wealth of knowledge acquired, mainly by and through the voluntary sector organisations that have done some wonderful work over the past 20 years, throughout the entire period of direct rule in Northern Ireland there had been virtually no co-ordination, no command and control hierarchy and no structured pathway for autism. I believe that this deficit is overall of national proportions and I shall concentrate on this issue.

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It appeared to me that the Hall and Elliman report, specifically the one known as the “Hall 4” report, in its conclusion that there was no foolproof method of screening for autism, was able to allow off the hook those who direct within the health service. Well, things have moved on. The team of professionals that I chaired has concluded that effective assessments of developmental progress are possible from around two years of age. That means in effect that, from January 2010 in Northern Ireland, 22,000 children aged two to three years will be screened each year.

One may ask whether that will be a massive and costly exercise, but that will not be the case. We already have in place—I assume that it is the same in Great Britain—a health visitor system, which over the past 60 years has successfully and willingly adapted to changing demands. It is eager to adapt and embrace up-training with regard to early identification of autism tendencies, which will be achieved at acceptable cost with the voluntary sector and departmental agencies working in partnership. Much of this is about efficiency gains.

In line with an expectation that roughly 1 per cent of the population is on the autism spectrum, we have calculated that 3 to 4 per cent of two years-olds will be queried, some 750 children per year in Northern Ireland. By assessing on the basis of population and with simple primary school maths, it will surely not be difficult to plan—largely, if not entirely, on the basis of the existing consultant provision—what is required to provide immediate early assessment and diagnosis. Each healthcare trust will know exactly what to expect and consultants can plan ahead, up-training themselves where necessary. They will refine the initial 750 children identified down to 1 per cent, which will probably be 200 to 250 children each year, who will from that early age be able to benefit from early interventions.

I come back to costs for a moment. We will be using almost the same professional practitioners, but in a way that is planned and structured better. Extra costs will occur but mainly in up-training, and those updated skills can be built into training programmes for those planning to enter the medical and associated professions.

Of course, that cannot be the simple end to my thesis. Children with autism spectrum disorder have to face transition to primary school and to secondary school and then they have to adapt to adolescence and so on. But is it not better to begin to learn to cope in the vital learning years between two and eight than for us to find a confused eight year-old with behavioural problems falling behind his peers and unable to adapt?

Here is the opportunity for progress, but it is not the end of the story. That is a matter for further adaptation and joined-up government. The Department of Health can break down the front door but every other department has to smooth the path that lies ahead: teacher training, police training, the Prison Service, sports clubs, the workplace and so on. I believe that each stage can be dealt with as effectively as we plan in Northern Ireland for the two to eight year-old phase. We do not have to reinvent the wheel; we do not have to tear down and replace existing administrative structures. We have to adapt to a reality

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that does not put our nation into and take it out of a series of disassociated stages. Life, especially for those with any disability, should be a gentle stream, not a series of waterfalls.

I conclude by asking the Minister and her noble colleague, the noble Lord, Lord Darzi, who has contributed so much, if they would look at the Answers that their department gave me on 20 May over the signature of the noble Lord, Lord Darzi, at col. WA 312, regarding the plight of those on the autism spectrum who find themselves in prison—perhaps up to 30 per cent of our prison population. It was simply not good enough to have an Answer that implied, “Prisons and autism we don’t do; we don’t provide; we don’t really want to go there”. Given the Minister’s diligence and given the noble Lord’s industry since he came into this House, I do not believe that that it is what either of them would want.

4.15 pm

Baroness Tonge: My Lords, I, too, congratulate the noble Lord, Lord Walton, on securing this debate and on his excellent speech—not a speech, a tutorial—on the benefits of and need for medical research. I am sure that the House appreciated it. It was ably backed by the personal story in the speech of my noble friend Lord Rodgers. I thank my noble friend Lord Addington for reminding us that we should be thinking about a national health service. He reminded us that prevention is better than cure. I would add that my noble friend is not overweight; it is all muscle.

The National Health Service today is a strange organisation. It is neither totally planned from above, nor does it free its patients to obtain treatment and care from any health facility, public or private, that they wish. It is something of a muddle and rather confusing. It is leading to a lot of fragmentation and confusion. I shall illustrate the law of unintended consequences in some of the things that are happening in the health service, especially in medical education and research. Teaching and research used to be done primarily by the academic workforce in medical schools, medical faculties and the teaching hospitals, often in collaboration with doctors and physiologists in the non-teaching hospitals and using all the extra clinical material in those places. However, between 2000 and 2007, there was a fall of 27 per cent in the medical academic workforce. There are now only 2,937 academics working in our hospitals, medical schools and universities. Despite that, there has been a huge increase in the number of undergraduates: a 50 per cent increase in the number of medical students in the past 10 years, which is hugely welcome. The student population is currently 30,000, excluding all the postgraduate students, but that means that there is only one medical academic working in this country per 100 undergraduate students.

As a result of the decline in academic staff, there is more pressure on clinical staff in hospitals to teach and do research, but managers of those hospitals are often interested only in data collection, patient throughputs, targets and waiting lists. Teaching and research are very low on their radar screens and we heard from the noble Lord, Lord Warner, that PCT commissioning is questionable at times and does not always consider research and education.

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