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The Bromley by Bow Centre is about health, not sickness, which is reflected throughout the building. You enter through a beautiful cloistered garden, recently full of purple wisteria. There are no gruesome pictures of human bodies on the walls greeting our patients, the kind of images that used to haunt me as an imaginative eight year-old at our local doctor's surgery in Bradford. Instead, you walk into an art gallery and open-plan reception made of natural timbers and

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bathed in natural light. A high-quality environment, a focus on human relationships, open communication and customer focus are the keys to the Bromley by Bow approach. Doctors come out into the reception to chat and greet their patients in person. In the consulting rooms, patients and doctors sit side by side around curved wooden tables, looking at the computer screen together. At Bromley by Bow, doctors, nurses and patients work in partnership together.

Patients are not merely prescribed pills, referred and sent on their way. The drug we give to a patient with depression is only part of what our GPs prescribe as a fully comprehensive care programme. At the centre, we can offer on-site career advice; support to overcome debt; vocational training qualifications, and even a university degree programme; business support, including the opportunity to set up your own business; and practical housing and legal assistance.

Over the past 13 years the Bromley by Bow Centre has become an exemplar of an integrated approach to health and social care. It inspired the £300-million healthy living centre programme, run by the then New Opportunities Fund, and the £2-billion NHS LIFT initiative, which is of course the public/private partnership programme for building primary health and social care centres in the most disadvantaged areas across the UK.

Others have developed integrated approaches to health in other parts of the country. Dr Angela Lennox built a police station in her health centre in Leicester and reduced crime in the housing estate where it is based. The Westbank Community Care Centre in Exeter promotes healthy living across Devon. The Gracefield Gardens health centre in Streatham works in partnership with Lambeth PCT and Lambeth Council to deliver better healthcare. We ourselves now run three health centres for over 18,000 patients and are the largest primary care provider in the London Borough of Tower Hamlets.

I apologise for not being able to speak last week in the debate on the big society, but are these not all examples of where, in the micro, a big idea like the big society might take root? If integrated models of health and community care were encouraged in every community up and down the land, and the necessary local relationships and partnerships brought together, this important idea-the big society-might not become subject to yet further cynicism and be seen as more meaningless government spin with little substance underneath. It might actually become the fertile ground within which a wholly new definition of what it means to be a healthy society-a thriving community-took root. Of course, such an approach would need to be given time and consistent leadership.

There is a wealth of untapped social entrepreneurial talent in our country. Many of these entrepreneurs have it in them to generate creative and innovative approaches to primary and community care. There are hundreds of latent and undernourished third-sector organisations in this country with the capability to become like Bromley by Bow and take on the task of transforming how public services are delivered in communities up and down the UK. Our task is to find these people and organisations and put the wind in

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their sails. Over the past 10 years I have travelled up and down the country and discovered social entrepreneurs who are massively frustrated at how hard it is to be trusted and resourced to take on public contracts, including in the areas of health and social care. Despite the positive rhetoric from successive government Ministers, it has been intensely difficult for dedicated and talented social entrepreneurs to develop creative solutions.

My noble friend Lady Finlay and I offer the Minister a visit to some of these centres and the opportunity for him to see in detail what a successful integrated approach to health and community care actually looks like in practice, and what conditions need to prevail if it is to grow exponentially and to take root. The sad fact remains that these examples of an integrated health model are still few and far between. Despite all the rhetoric and promises, there has been little practical encouragement for these integrated approaches to health. It was ironic that our approach, which everyone now thinks is a great idea, was physically blocked by a boulder across our road to delivery back in the mid-1990s. The boulder was not local people but the local health authority at that time.

I am not convinced that things have moved on much. Yes, money has been spent on building new buildings and, yes, there has been investment in services, but the principle of broadening the base of primary and social care delivery and engaging social enterprises has barely been understood. I am aware that the language of social enterprise is spoken inside Whitehall, but I am profoundly doubtful as to whether it is understood. Indeed, the evidence is that it is not. Our public services need to be known for doing and achieving, not just endless talking, restructuring or writing yet another new stack of policy documents. In a modern enterprise economy, we are nowadays returning to the sensible practice of "learning by doing". The idea that we learn much through the writing of endless documents that are out of date within weeks can seem rather outdated. There is nothing better than getting your hands dirty in the practicalities to really understand what is going on. When I spoke to the recently departed chair of NHS London, he told me that his mission was to build stand-alone "medical model" health centres without what he called "the distraction of social and community care". Evidently, the complications inherent in the lives of disadvantaged Londoners were outside the brief of the chair of NHS London.

Similarly, the vision of the noble Lord, Lord Darzi, of a network of polyclinics, announced in your Lordships' House, was in practice another missed opportunity. When you get into the practical detail with those of us who are practitioners, you see that it was not at all a vision of polyclinics, but of monoclinics-that is, health centres that are almost solely about the clinical model of healthcare. It is a sophisticated clinical model and, invariably, these clinics are full of state-of-the-art equipment and procedures. However, I am vexed to say that they pay scant lip service to the lessons many of us have learnt about integration and the bringing of different disciplines together in the way I have described-that the route into addressing the pressing and underlying health needs in some of our most challenging communities

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in this country lies in getting GPs to work with their non-health colleagues. It is as simple and as complicated as that.

We need our health service to be open to working in partnership with the third sector and social enterprises in integrated schemes which address the real, practical day-to-day issues that face patients. These include poor social housing, underachievement in education, credit card debt and fear of bailiffs, concern over street violence and anti-social behaviour, and the lack of opportunities to take control of their lives. We are not asking the NHS to solve all these problems. We are simply asking that the health profession be willing to work more collaboratively with others who have the tools to change our communities for the better, including by addressing their physical and mental health needs.

What those of us who have had real experience of running successful integrated health centres found was that the definition of a polyclinic changed on a six-monthly basis, and each new definition was communicated by NHS London with such clarity and certainty that real players and practitioners in the field were left totally paralysed. This meant that important health centres still remain not built, with enormous potential abortive costs. I know of one health centre that has had to go through so many NHS London-inspired redesigns that it has incurred over £1.5 million of design fees and still sits in NHS London's in-tray. I truly wish I could say that this is the only example I am aware of in London but it is not. I am afraid that the last Government were rather fond of initiatives that never in practice happened, and of trusting the reports of young consultants at McKinsey rather than those who do the job.

I welcome a world envisioned by the coalition Government where resources are put in the hands of practitioners on the ground with a real understanding of their neighbourhoods and local needs. However, this vision is far from straightforward. Not all GPs will deliver the integrated model of healthcare that I described earlier. Many GPs who support an integrated approach tell me that their colleagues who do not support it fear loss of status and title, without realising that real status in communities is based on the strength of their relationships with patients. Often in deprived areas there is a stark lack of GPs with the capacity to rise to the challenges that they now face. This new approach has important implications for the ways in which doctors are now trained.

The Government need to ensure that GPs are encouraged not to resist change, nor protect an expensive biomedical model of health. We need to show our doctors that an integrated approach to healthcare will address the profound problems that people in disadvantaged areas face, with considerable savings to the public purse. At Bromley by Bow, we run our health centre like any successful customer-focused business. For example, 20 per cent of consultations are conducted on the phone, which saves not only the patient's time but the GP's as well. What we all have to realise is that the NHS has access to people across the country which any business would die for. Eighty per cent of consultations in the NHS take place in general practice, and 90 per cent of the population is seen in any one year. If we encourage entrepreneurship in the world of

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health, then the more capable practitioners will step into these gaps in the market and ensure successful delivery of care.

As the new Government begin to formulate their health policy, I have three questions for the coalition and the Minister, who I wish to thank for a very helpful discussion earlier this week on this subject. First, what is the Government's vision for the future make-up of primary and community care? Will they simply leave it to the marketplace? Will they promote the standard medical model or the integrated approach of the type I have described? A clear approach is essential for the dedicated medical staff, who have had to suffer countless changes in direction over the last decade and now feel disillusioned, confused and frustrated. Secondly, once the Government have clarified what their future model of primary care and community care will be, how will they deliver and develop this approach effectively? This has simply not been happening. Finally, who in the coalition Government will lead with consistency and longevity, and pursue this course? Under the previous Government, we saw a succession of initiatives and restructuring led by "here today, gone tomorrow" Ministers, which has left the health service, frankly, in ill health. Who will be the leader? That is my key question.

The Government are rightly opening up a world of opportunity and I welcome that. However, the devil, as ever, will be in the detail and perhaps most importantly in consistent leadership not from civil servants but from practitioners-GPs and others who have done the job and understand the practical details on the ground. I encourage the Minister and his Government to lessen their reliance on academics and theorists, who have often never built anything, and to embrace the world of the practitioner and the social entrepreneur; to create a culture where we learn by doing, and not by talking and writing endless expensive documents and papers. We cannot afford this expensive, rather old fashioned way of doing things any more. Let us support-and learn from-people who do the job.

2.56 pm

Lord Colwyn: My Lords, I congratulate the noble Lord, Lord Mawson, on securing this debate. I listened to his speech with great interest. He has a splendid vision for future healthcare and should be congratulated on all that he has done. I hope he will forgive me for not following directly his line of thought. I am not used to speaking so early in a debate; normally every subject has been covered by the time I get to my feet. I must concentrate on matters that have affected and will affect my dental colleagues. I have no need to declare an interest. I was in dental practice for more than 40 years but I have now been retired for two or three years.

As I said in the debate on the Queen's Speech, the past 10 years have seen fundamental changes to the provision of dental services. We have been left with unfinished reform of NHS dentistry and must now work to deliver a better system both for patients and dentists, even at this time when the Government are making complex financial decisions which will affect us all. Alongside the challenges of oral health promotion

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and NHS dentistry, general dental practitioners face mounting challenges in the management of their practices. The creation of the Care Quality Commission, with which both NHS and private practices must be registered by the end of March next year, imposes a further layer of regulation on dental practices.

Why this current explosion in the evaluation, accreditation and remediation of health professionals? The CQC emphasis is on the registration and inspection of practices, rather than the assessment of individual performance. This will probably be followed by the General Dental Council's proposed revalidation processes, focusing on individual registrants rather than the environment in which they happen to be working. There will be areas of overlap, which will need to be looked at to avoid duplication and possible misinterpretation.

The British Dental Association's Good Practice Scheme recognises the practice, not the individuals within it, and Denplan Excel has, for nearly a decade, been independently auditing dentists against a full range of quality and oral health measures, regularly visiting the practices and de-accrediting those found wanting. The BDA has identified a significant surge in the demand for advice on regulatory issues. It says:

"It is clear from our analysis that the challenges facing dentists are increasing and changing".

Paramount to its concerns is the growing burden that changes to professional regulation are placing on its practices and the impact it is having on the delivery of patient care. The BDA continues:

"Recent years have seen a significant and disproportionate elaboration of the regulation of dentistry, with the publication of new decontamination guidance and the advent of the Care Quality Commission. We hope that the (recent) announcement of the halting of the proposed vetting and barring regulations signal a fresh approach to regulation that puts patient care before bureaucracy".

Dental Protection, the dental branch of the Medical Protection Society, which I used to have the honour of chairing, reports an unprecedented demand for its advisory services. It says:

"The controls are out of control".

There is a widespread feeling in the profession, and a growing sense of anger and frustration, that there are too many hoops for practitioners to jump through, often resulting in a duplication of effort and with no real justification in most cases. The evidence base for many of these new requirements being imposed on dental practices is sketchy or non-existent. We desperately need a more balanced, logical and measured approach whereby any additional layers of governance are scientifically based and targeted where they are justified and most needed, rather than being applied across the board. The current environment is wasting the time, energy and money of many practitioners who are already doing an excellent job for their patients.

At a time when the new Government are proposing that high-performing schools should be inspected less often and freed from unjustified bureaucracy, the current excesses in the regulation of dental health professionals are impacting upon morale, deflecting effort and resources and ultimately not serving the best interests of patients. Now that many NHS practices are effectively operating on fixed incomes, any unnecessary expenditure in one

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area needs to be funded by cutting back on more constructive expenditure elsewhere.

I have received many letters from dental colleagues. I wish to quote from one that I received from Caroline Thornton, who practises in Gloucester. She comes from a family of dentists. Her grandfather was a dentist, as were her father, her brother and her husband, and she wants her 16 year-old daughter to become a dentist. She writes:

"We are trying very hard to conform to the avalanche of regulations piling up every day. However, in a recession, this is proving to be very expensive! We have spent thousands on a new sterilization room, paid for the nurses to be trained, registered, and their CPD up to date, CRB Checked, even though 2 are pregnant. We are having one of the surgeries revamped in August to make sure it is up to date with the HTN 1-5 regulations at a cost of £20,000, and even completed a clinical waste audit, amongst many other trivia, all at our own expense. At this rate we will have a lovely practice but be bankrupt!"

I could quote many other letters.

One detail that seems to be overlooked in this eagerness to be seen to be monitoring, documenting, auditing and acting is that when assessing the risk presented by an underperforming dentist, it pales into insignificance when compared to an underperforming medical practitioner or surgeon. Before all this monitoring, documenting, auditing and acting became an art form, how much actual damage was being done to how many dental patients? How often and how serious were the consequences? Medics can kill people. Even at the very worst, dentists are unlikely to do so. I am tempted to wonder whether we are creating an entirely new industry and spending an awful lot of money "fixing" an illusory problem, or heading off the hypothetical threat of a "virtual" problem that may not even exist in reality.

3.03 pm

Lord Rea: My Lords, I thank the noble Lord, Lord Mawson, very much for raising this important topic, and particularly for his inspiring description of his Bromley by Bow project. It reminds me of the Peckham health centre from pre-war days, which was a concept ahead of its time. It is now, sadly, closed. There is much we can learn from the noble Lord's project and his words this afternoon.

The noble Lord has worded his Motion constructively, concentrating on recent changes and the lessons to be learnt; basically, what has worked; what has not worked; and what might work better. If we were to start with a blank sheet, we would need first to look at the kind of health and social problems which the population presents-of course, the two are inseparable-both nationally and locally and then try to fit services best to tackle these problems. However, we have to build on what we have. As the noble Lord has described, this is far from ideal, but I am an optimist and I think that it is getting better. It is already a lot better than in many other countries.

Of course, we have an age pyramid typical of a western developed economy, getting top heavy with older people such as myself-there are more and more of them-and they are living longer and, sadly, becoming increasingly disabled, needing more care. Other than this demographic problem, the other main public health

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problem, which we share with the rest of the world, is the difference in health status between the best off and the worst: health inequality, in other words. This gradient applies throughout the social spectrum from top to bottom. We need to improve the health not only of the poorest but also of the middle of the range who have worse health than those on the next rung of the ladder and so on, as Professor Michael Marmot has recently re-emphasised. To restrict services such as Sure Start to the really poor and deprived does not tackle the relative health problems that exist, for example, between skilled and non-skilled manual and non-manual workers. There is work to be done right across the board.

Ideally there should be a gradation of health and social service funding taking into account the age and social structure of each community. To be fair, there has for many years been a serious attempt to do this, but the inverse care law still persists and it needs an even greater share of resources than we have so far allocated to it to reverse it. This might be politically difficult since if this was done on a tight budget, as now, and was in some years past, relatively well-off communities might have to accept a reduced budget. These communities know how to fight their corner, so it is a difficult situation. The health problems of ageing and inequality are deep-seated and have their root causes in the nutritional, physical and social environment of early childhood, which is largely outside the scope of the community health and social services. Even so, it is these services that have to cope with the lasting legacy: the social problems of young adults, including drink, drugs and crime and the chronic ill health of older adults.

Though those with chronic degenerative illness often need periodic admission to hospital, most of their care is appropriately and better done in the community. In a minority of cases "hospital at home", including procedures such as intravenous drips, is sometimes possible, avoiding admission or enabling early discharge rather than treatment as an as an in-patient. However, the Royal College of Nursing is concerned that the development of specialist home nursing teams such as advanced nurse practitioners, community matrons, specialist nurses, and consultant nurses concerned with managing serious illness at home is having a knock-on effect in reducing the recruitment of community nurses and health visitors, who are still vital in overall community care, particularly for the disabled elderly at home, and in providing mother and child care and preventive services. The transfer of much hospital care to primary and social care at home has long been part of government policy but is not always cheaper. Patients may be discharged too early and need re-admission-a process perhaps encouraged by the payment by results scheme, which can result in a hospital being paid twice, once for each admission.

For many years, GPs have increasingly come to accept that they need to work in teams-not all, I agree, but the trend is there-including other health and social workers to give a really effective service. There are still a few Dr Finlays out there who prefer to work on their own. They are very different from my noble and professional friend on the Cross Benches. The primary care team is now the norm and is encouraged

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by the National Health Service. As the noble Lord said, my noble friend Lord Darzi proposed a network of polyclinics in which there were more services and links with hospitals than in most group practices, but this proved to be a bridge too far for many GPs and their professional organisations. However, the concept has become more acceptable, provided that the centres are GP-led and tailored to local needs and development. Many GPs are concerned, however, that the polyclinic concept will lead to primary care groups being taken over by private profit-making healthcare companies. This has occurred already in some PCT areas. The one that I know is in Camden PCT, where the contract for practice was awarded to United Health in preference to a local GP group which was offering a better and fuller service, but at a slightly higher price. The results have not, as far as I am aware, been fully evaluated, but the local feedback is unfavourable.

The new contract for general practitioners brought about major changes, as well as a rather generous package for most GPs. The BMA had a sharp negotiating team and the Government needed the GPs to be on board. The biggest change was to remove the obligation to provide 24/7 out-of-hours clinical cover for registered patients. PCTs had to take on this responsibility. They have not found it easy and have often farmed the work out to private companies. Patients are not always happy to be seen by a strange, often foreign, doctor who does not know the area; and of course there has been the occasional tragedy, as we all know. This is a far cry from the days when I was a general practitioner, when we were responsible for after-hours care. Our group made it tolerable by collaborating in a consortium or rota, with other local GPs. In fact, the BMA negotiating team was prepared to continue with the responsibility, if the money had been right. In the end, however, the cost to the PCTs of providing the service was much higher than estimated; in fact, according to my information, it was greater than the amount that the BMA had originally asked for.

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