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I begin by congratulating the Government on administering a speedy coup de grâce to the ill-conceived Personal Care at Home Act. This has removed an important roadblock to achieving sustainable long-term reform in this area. Unlike the noble Lord, Lord Sutherland of Houndwood, I welcome the idea of an independent commission to look into this. I think that we need to dig quite a few people out of rather entrenched positions on some of these issues, and a commission of independent mind might help us to do that. However, it is important that it focuses quickly on the considerable amount of common ground that exists among different shades of opinion in this area. A few of us identified this common ground in March in a pamphlet produced on a cross-party basis with Sir Derek Wanless. I know that Ministers have seen that pamphlet but when we were writing it, it was very clear that there was a large measure of agreement on many issues in this area, and that is something on which the commission needs to build.

It is clear from the public debate so far that total funding for adult social care has to be increased significantly to cope with demography. It is also clear that there has to be a larger contribution from individuals and families who can afford it, rather than from the taxpayer. It is equally clear that risk-pooling through some form of insurance has a key role to play. These points are all well documented and well settled, and we need to build on them. We need to do more-and I hope that the commission will do this-to engage the insurance industry in ways forward in this area.

Before leaving the subject of social care, perhaps I may say a few words about the idea of a national care service. Like all parties, the Government rightly want to achieve more integration of health and social care for the benefit of service users. No one could disagree with that. However, I suggest that a better starting point for improved integration is the local commissioning role, rather than just concentrating on the provider side. This will particularly be the case if GPs are to be more powerful service commissioners in the future. We now need joint commissioning which supports more personal budgets and user choice and which creates greater diversity of service providers. It seems

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to me that the rather statist-sounding national care service is not self-evidently the best way to achieve this, and we need to look at that idea very carefully before we take it too much further forward.

I turn briefly to the subject of dementia, which has been raised a number of times today. I support and welcome the Government's decision to prioritise dementia research but I would encourage them to think more widely about whether the current allocation of service and financial responsibilities for dementia between the NHS and social care is right. After all, dementia is very much an illness; it is a disease, and I wonder whether the NHS is bearing its full proportion of the burden in this area. Another look at that might change some of the calculations that the independent commission might have to make in adult social care. I do not have a strong view on that, but it is an area that we should look at again.

Turning to the NHS, the Labour Government's record on investment in the NHS was outstanding. We recognised that that needed to be done after almost two decades of parsimony in the 1980s and 1990s. I shall not recite all the figures; many in this House have heard me recite them from the Front Bench many times. However, I emphasise one point: the independent evidence from the Nuffield Trust shows that the much maligned targets did a lot to improve services, however much NHS staff disliked them. Before we ditch targets we should consider whether, in a democratically parliamentary accountable system like the NHS, we have a few levers in Richmond House that enable us to satisfy the public that taxpayers' money has been spent reasonably well.

Latterly-the noble Baroness, Lady Murphy, put it very well-my party lost its appetite for NHS reform and certainly lost its appetite for some of the agenda that was promised in the 2005 Labour election manifesto, particularly those parts about more competition and greater diversity of providers to give patients more choice. I am a little hesitant about asking the coalition Government to help to implement that Labour Party manifesto. I notice in the new health Bill that this Government are to make Monitor into a proper economic regulator, a move which I have long supported. This is a good opportunity to ditch, once and for all, the rather misguided idea of the NHS as a preferred provider. A good start could be made by starting with market-testing PCT provider services, which the Department of Health has already said are inefficient and lacking in good productivity. I wonder whether the noble Earl can say whether there will be a review of some of the mergers that have quietly taken place or are in prospect of some of these less than efficient PCT provider services.

There is not time for me to go into any other areas of the NHS. As the new Government tackle the very difficult financial challenges ahead, which the NHS has never faced in its history on this kind of scale, I hope we in this House can settle down and discuss all these changes, which would have been inevitable whoever had won the election, and start doing so in a constructive and non-partisan way.



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4.32 pm

Baroness Emerton: My Lords, I, too, welcome the noble Earl, Lord Howe, to the government Front Bench and offer him my congratulations on his appointment as Minister for Health. I am sure that his experience, knowledge and wisdom will be invaluable in taking forward the five priorities set out by the Secretary of State for Health and the long list of proposals within the health section of the coalition programme for Government. I also congratulate the noble Lord, Lord Hill, on his appointment and his mastery of the subject in his opening and maiden speech. I welcome my noble friend Lord Kakkar to the Cross Benches and congratulate him on his maiden speech. I am sure that his expertise in the area of medicine will be of great benefit to the deliberations of this House.

As I read the coalition Government priorities in the health section, I could not resist casting my mind back to 1953 when I started as a student nurse. At that time the ward sister reigned supreme and the matron was to be obeyed not only by the nurses but also by doctors and administrators alike. In my time, I have experienced six major reorganisations of the NHS, all of which had good points. I agree with my noble friend Lady Murphy that changes of organisational structures are sometimes good, but there are also things which are not so good. The one that stands out and disappoints me is the lessening of authority and accountability of the ward sister and the community sisters through to the director of nursing, both in hospitals and in the community. Therefore, I am delighted to read that:

"We will stop the top-down reorganisations of the NHS that have got in the way of patient care. We are committed to reducing duplication and the resources spent on administration ... We will cut the cost of NHS administration by a third and transfer resources to support doctors and nurses on the front line ... Doctors and nurses need to be able to use their professional judgment about what is right for patients, and we will support this by giving front-line staff more control on the working environment".

It important for us to note that professional judgment and working with more autonomy and higher levels of the critical thinking and problem-solving skills are core elements at the heart of the Nursing and Midwifery Council's review for pre-registration education and the move to the degree, under which the Nursing and Midwifery Council register will from 2013 require all registrants to have a degree. All those standards have a clear synergy with the Government's vision of the role of the future professionals in the NHS. The proposals all echo the recent recommendations of the Burdett Trust for Nursing in Leadership and the Business of Caring, the RCN's recent work on strengthening the role of the ward sister and the most recent recommendations of the Commission on the Future of Nursing and Midwifery Professions.

I very much hope that the coalition Government will grasp this opportunity to develop and enact those policy statements with the benefit of improving the quality of patient and client care; ensuring that there are clear lines of accountability and authority well-defined and understood from the patient, the client and the public level through to the board level, including enhancing the role of the nursing voice at board level; and being knowledgeable of the wider context of the

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NHS, conversant with modern nursing practice and measuring clinical outcomes both in hospital and in the community.

It is also important to note that the announced cuts in finance will not exempt the multi-professional education and training budgets and that the current £4.8 billion will be reduced by 10 per cent, most affecting undergraduate and postgraduate education in medicine and dentistry. The £0.8 billion which is used for continuous professional education and national innovations is the most vulnerable. That raises concerns about the Government's ambition to raise quality of care standards and the future shape of the workforce. Balancing the necessary cuts to meet the overall deficits will require the highest quality of medical and nursing professional management skills to ensure a workforce that will protect the safety and well-being of patients, together with the priority to raise the profile of public health, which will require knowledge and expertise so that clinical outcomes of patient experience and safety are met, as well as meaningful health promotion and prevention of disease being developed further.

I refer to two other important issues. The Government have said that they will seek to stop foreign health professionals working in the NHS unless they pass robust language and competency tests-a crucial policy requiring action to change the current interpretation of the EU legislation, the professional qualification directive 2005/36. This prevents regulators from assessing the language competence of EEA professionals before admitting them to the registers. Currently, assessment is left to employers, not the regulators, and ignores the fact that many health and social care professionals are independent practitioners who practise outside the NHS and formal management assessments. The Nursing and Midwifery Council exists to safeguard the health and well-being of the public, and all nurses and midwives on the register should be safe and effective in practice, but the regulator is not permitted systematically to language-test trained applicants, therefore undermining the integrity of the register and presenting a risk to the public. The situation is also confusing to employers, applicants and the public, leading to a potential risk to the health and well-being of the public.

I ask the noble Earl to ensure that the 2012 review of directive 2005/36/EC on the recognition of professional qualifications reflects these concerns. Health and social care professions from outside the UK make a significant contribution to healthcare in this country, but patient safety must always take priority over free movement of labour.

While I share the concern of my noble friend Lord Sutherland about the delay in the introduction of long-term care and the suggestion of a commission, I hope that the Government will quickly take forward the commission and bring forth a sustainable structure of funding for long-term care. The part played by nurses and social care workers will be crucial in establishing the three Ps: prevention, personal and partnership. I should like to add the three Cs: care, compassion and communication, which are all essential ingredients that the public are looking for, especially in the light of the recent inquiry about Mid Staffordshire that demonstrated so clearly unacceptable levels of care. It

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pointed to the need for a highly competent workforce, high levels of supervision and management within a culture conducive to demonstrating compassion and communication with the flexibility to cross boundaries from health to social service and other partners. There is no doubt that there is a formidable list of proposed policies and I wish the Government well in taking them forward.

4.40 pm

Baroness Knight of Collingtree: My Lords, it has been a delightful and somewhat unusual experience to sit here hour after hour today hearing a deluge of praise and kindness showered upon my noble friends on the Front Bench. Every word was said with such meaning. I appreciate it very much and would like to make it clear that we on this side of the House are just as delighted to see my noble friends on the Front Bench in government as members of the Opposition have kindly suggested.

The stated aims of the Government's new health Bill are excellent. There has long been a crying need to improve basic healthcare for our citizens. I thoroughly approve of doctors and patients being given greater control. There should be devolution of power and responsibility in the NHS. We all understand that there must be management of the hotel side of our hospitals-the laundry, the cleaning and the cooking-but people who know nothing about medicine are not the ones who should be the captains of the hospital ship, as they often seem to be.

Administrators are not the best people to improve bad standards. They are far more likely to sack a whistleblower than to listen to the complaint and try to do better. Even when I have complained about the disgraceful treatment of patients, the reaction has invariably been outrage that I should dare to criticise and flat denials that anything at all is ever wrong with the treatment of patients rather than what I would have far preferred: an apology and a promise to investigate and do better. I have always been very careful to report only cases where I can give names, dates, witnesses, addresses, ages and the hospital where the incident occurred. Your Lordships will have often heard me speak in this House of such cases. Many have been of patients who have been given neither food nor water, or-and I find that this is extremely common-whose food has quite deliberately been placed too far away for them to reach and has then been whipped away untouched with not even the slightest offer to try to help them with feeding. Those who have no one to watch out or speak up for them are in terrible trouble. Some time ago, an elderly man in exactly that situation was actually filmed on TV as he starved and died.

There are many, many cases of patients being treated without care or compassion. Relations often fear to complain, in my experience. Sometimes they say, "Well, he's dead anyway, we can't bring him back, and if I complain I will really be in trouble because that complaint will go down against me and my care may suffer when I need it". One instance has been cited a number of times by many different sources. A patient begs, even screams, for help to get to the lavatory, but is completely ignored and given no help at all. Eventually, helpless, they let loose in the bed, and what happens? They lie

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in the mess sometimes for hours before anyone comes to wash and change the sheets. Sometimes the excuse is that there is a wait until the next team comes on in the morning, but often no notice is taken at all of their predicament, which is appalling. I have absolutely no doubt that there are still angels among the nursing fraternity-we have some of them in this House-but I am afraid that they are a lot rarer than they used to be.

Only eight days ago, one major newspaper reported two quite separate examples on two quite separate pages of the lack of the most basic standard of care: one in a private home, and one in the NHS. The former was an 84 year-old man who was placed there because his wife could no longer care for him. He had Alzheimer's and was both deaf and blind. After only one day, the first family visitor to see him found him on all fours, wearing only a nappy and covered with bruises and dried blood. When he was admitted, he had three bed sores. A few days later he had 18, all of which were covered with dirty dressings. He died six days later as a result of no proper treatment for the sores. The noble Baroness, Lady Masham, spoke of a similar case. Sadly, she knows as well as I do that there are many of them. One can only imagine what agony that poor old gentleman must have endured. As his inquest, the coroner ruled that he had,

In the same newspaper on the same day, a journalist wrote of her treatment in an NHS hospital. She had had surgery on her back and had no complaint about that. The surgeon was excellent and the operation went well-that was all absolutely fine-but the standard of nursing care afterwards was abysmal. "On the ward", she writes:

"I was treated like a malingering bed-blocker ... When I asked for pain relief, it was refused. When I asked for help in moving, it was refused".

One can imagine that after a back operation she had great trouble trying to move. She went on:

"When I asked for a second pillow so I could sit upright, it was refused",

even though every other bed had two pillows. She asked for help with another extremely painful condition from which she suffered. That help, too, was refused, although by then she was hallucinating and crying from the extreme pain that she was in. I will draw a veil over the rest of her account, and report only the last words that she wrote. She said:

I always came to the conclusion that the previous Government believed that the excellence of care could easily be measured by the number of millions of pounds spent on the health service, a point which has been touched on in this debate. That is wrong-I repeat, wrong. It is not how much money is spent, but how that money is used which is so important. That yardstick took no cognisance of the standard of care a patient received.

Our new Health Minister promises that his Bill will focus on quality and the needs of patients, which we have wanted for years. It seems that new Ministers

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have watched and learnt. How pleased we were to see only yesterday that details would be made clear about how many patients have died from MRSA. I was staggered to see a report that the number was 8,000. Whether that is accurate or not, we shall soon know. Whatever is or is not done, and however many millions are spent on the health service, if the patient's well-being is not the first priority, the service fails. That message should be framed and placed on the desk or a nearby wall of every Health Minister.

4.51 pm

Lord Mawson: My Lords, I should like to add to the deluge of praise. I congratulate the new Government on their success and wish them well in the coming years as they try to develop a working partnership and deliver their programme. I also want to take this opportunity to wish the Minister, the noble Lord, Lord Hill, well in his new job and to thank new colleagues for four excellent maiden speeches. I also congratulate the noble Earl, Lord Howe, on his new appointment.

As a result of many years of bringing disparate groups of people together to deliver practical results, I know that the key to partnership is to focus on relationships and not just on new structures, processes and strategies. Focus on the relationships and everything will follow. Ignore them and you will face serious difficulties. My colleagues and I have spent more than a quarter of a century bringing together partnerships to modernise public services so that they are more responsive and fit for purpose in our modern enterprise culture.

I thought that it might be helpful if I shared with the new partnership Government a few lessons that my colleagues and I have learnt at the coalface. It might also help them to put some flesh on the bones of what the big society might look like in practice. Many people are wondering what this piece of marketing means. We all know that it is crucial for a new Government to lay solid foundation stones on which real change and development can grow. Real change is elusive and may not come to fruition until a Government have left office. Effective innovation can take a generation and requires committed individuals to champion it. It is rarely captured in a policy document, written by what my colleagues affectionately refer to as "the bright, young things". Real change has to be grown and deeply rooted in communities, otherwise, as I suspect that new Labour is discovering, it will be blown away like the sand when the first gust of wind comes along.

What are the lessons? How do you create a big society and lift the game in education, health and welfare? First, I would suggest that this Government support organisations that already have a successful record of reforming public services. Do not reinvent the wheel, but build on what works. They should back success and learn from their many years of detailed practical work. Do not, as new Labour so often did, take their best ideas, pass them to the Civil Service machine and exclude these experienced innovators. Let them take the wheel. Support them and enable their efficiency. Do not think that it is now the Government's job to take control. It is not. They should take the long-term view.



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Secondly, we need to question what the overused term "fairness" means. The question to ask is: fairness for whom? If you are seeking to achieve fairness for Karen and her children on housing estates across the country and to improve their educational opportunities or access to health, you must back the best providers with a proven record. It is irrelevant whether they come from public, business, social enterprise or voluntary sectors. However, if you are seeking to be fair in dishing out grants and resources to the voluntary sector, you will do something quite different. Who are you trying to be fair to and why? Life is not fair, and where we began to challenge and question this thinking in east London and embrace not equality but diversity, a thousand flowers began to bloom. "Fair for whom?" is the exam question I leave with the Minister. It is not possible to be fair to everyone.

Thirdly, if fairness is about creating opportunities for employment and improved services, the future must be about enabling environments where business and social entrepreneurs can do business together. These are the new relationships that will reform public services and they are already showing significant success, but this means that some of our cherished ideology will need to be examined and probably dropped. For the last decade, bureaucrats have fed a bureaucracy monster and it is now very large indeed. Often, contracting out has transferred a large government bureaucracy to private sector companies with large contracts-prisons, for example. Then the civil servants have migrated from one large organisation to another. The contracting process seems designed to stifle innovation and risk taking. The role of the new Government needs to be to create a level playing field where new relationships and networks can grow, particularly between business and the social enterprise sector.

Fourthly, I would ask the Minister how he will practically encourage new environments where people "learn by doing". Will he get his hands dirty by planting the seeds of enterprise in the fertile soil outside the comfortable but dry world of theory? If this new generation of politicians is to gain any understanding of how the real world works in practice, and not hide in the bubble of Westminster, I would humbly suggest that each Member of Parliament should become involved in one project in their constituency to play their part in building the "big society". Do not pontificate about it: do it. Legislators might then begin to understand the relationship between legislation and practice because attempting to deliver a new school, health centre or service is a practical nightmare nowadays, given the number of contradictory hoops laden with half-baked ideology that practitioners like me have to jump through. The confusion that exists between delivery and democracy is a minefield. The micro is the clue to the macro. Learn from it and gain the public's respect in the process.

If this Government are serious about empowering communities, Ministers will have to get involved in messy detail. For example, one of the difficulties we face in giving people more professional independence in health is the awkward fact that often doctors do not want to innovate. They have not been trained to think like entrepreneurs and so resist change because they have an entrenched view and an expensive biomedical

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model of health to protect. This is not just my view, but that of the doctors I have worked with. Can we leave commissioning with doctors? Will they be responsible? It depends on the mindset of the individual doctor.


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