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The other important part of the new contract was the QOF-the rather grandly named "quality and outcomes framework"-whereby GPs receive a payment for each procedure in a list of measures which assist in monitoring, and thus improving, the health of their patients. They include weighing, taking blood pressure, keeping disease registers and so on. I and some of our colleagues were sad that GPs had to be paid for measures which many of us regarded as part and parcel of good practice, and should have been part of any contract. However, it is clear that this carrot has increased the capacity of general practice to anticipate serious illness. The standard of practice has improved and some lives may well have been saved through, for instance, control of blood pressure and weight reduction. However, I am sceptical about the accuracy of some of the numerical extrapolations that have been made about lives saved. It would be good to know whether, without the financial incentive, this exercise will result in permanently better practice by GPs.

An alternative or addition to the polyclinic model has been suggested by the Royal College of General Practitioners. It proposes primary care federations, which are associations of primary and community care teams, as a legally binding enterprise. I am sure

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that that concept is not unfamiliar to the noble Lord, Lord Mawson. The college cites three examples: the Croydon Federation, consisting of 16 practices; Lincolnshire General Practices, which has14 practices; and Epsom Downs Integrated Care Services, where 20 practices are collaborating. These hold considerable promise, but I should like to see more involvement of social services and mental health teams, as well as appropriate parts of the voluntary sector. This is very much in line with the proposals of the noble Lord, Lord Mawson. As it is, these projects provide better-integrated primary and community care as well as more emphasis and better facilities for preventive medicine and health education. They could also help to form, through their PCT, a nucleus for practice-based commissioning, which so far has had little impact on services provided by hospital trusts.

Local collaborations such as this, which very much fit the ideas of the noble Lord, Lord Mawson, including voices from all the caring professions, are more likely than top-down decisions to provide or commission good services for their communities.

3.15 pm

Lord Alderdice: My Lords, like other noble Lords, I commend the noble Lord, Lord Mawson, on obtaining this debate, particularly in this area of healthcare-the bringing together of primary and community care and learning practical lessons from the work that has been done.

Until my retirement from psychiatry and the NHS at the end of March this year, I had worked for many years in healthcare in Northern Ireland. As some noble Lords will know, we have had a fully integrated health and social care system since the early 1970s. This has been enormously beneficial. Let me give noble Lords some idea of what it means. When I was working as a psychiatrist, a patient would be referred to me by a general practitioner in the same trust. I would see the patient as an out-patient, and I would have at the clinic, as part of the multidisciplinary team, nurses, social workers, psychologists, as well as junior medical colleagues. Indeed, secretarial and administrative staff were very much regarded as part of the team because they would meet the patients. How the staff related to patients on the telephone or in reception was an important part of managing them. If they needed to be admitted to hospital, the same team would be able to work with those involved in patient care and the patients. All these teams included social care. Social services staff were as fully involved in the trust as the medical or other professional clinical staff.

With regard to the management of the trust, a manager of doctors might have been a doctor but they might also well have been a social worker, an experienced nurse or some other professional within healthcare. It meant that people were able to work together right across the disciplines with the single concern of ensuring the best possible health and social care for patients, whether they were at home or a daycare facility or whether they were short or long-stay in-patients.

My noble friend need not be concerned; I am not proposing that there should be structural changes in the healthcare system in England, but that structure

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facilitated us in working as multidisciplinary teams. However, we discovered that there was a limit to multidisciplinary teams, because after a time it became apparent that there still had to be an element of leadership. It was not enough to get the professionals to work together as though everyone had the same role and the same responsibilities; it became apparent that there was a need for leadership. Whether that came from the medical side or from social work, psychology or nursing was much less important than the skills that the individual had as a leader. Being a leader is not a particularly professional qualification; it is a personal one.

I say to the noble Lord, Lord Mawson, that for many of us a medical model is biopsychosocial. The notion that it is only about the physical and does not include the mental, emotional and relational is, from my point of view, a rather perverse idea of what medicine is really about. However, I accept that there has been a tendency for doctors and others outside medicine to push medicine in that direction, and it is down to those of us who believe in something different to open up the windows and to help people to understand that we are talking about not just the whole person but the whole person in their relationships with others. That is all part of good medical work.

We did not just find a limit to the notion of multidisciplinary teams; we also found a very definite limit to the notion of managerialism. Of course, as things became more complex and finance became involved, it became necessary to have managers and administrators. At the start of the process, they were seen as serving the requirements of professionals and patients. However, it was not long before they began to regard themselves as the bosses of the clinicians-and indeed sometimes of the patients as well. They would be far less concerned about the professional and clinical requirements or the requirements of the patients than about balancing the books or having a growing managerial empire. Every time there was a reorganisation and restructuring, the one group that never seemed to reduce in number was the managers. There always seemed to be places for them to go and none of them ever seemed to be made redundant in restructurings.

The truth is that an arrogance began to develop whereby the people at the centre, whether they were managers or in Whitehall, felt that somehow they had more real interest in, concern about, knowledge of and expertise in what was good for patients and patient care than the people who had committed themselves to that work from the beginning of their professional lives. Some of the managers came from business and had no real understanding of the complexity of healthcare. However, they were encouraged by Governments who saw a market model as being the way to run a healthcare system. That never seemed to make much sense to me because, if the bottom line was important for you, the best thing you could do was to let many of the patients die as quickly as possible so that they would not be a charge on the state.

The market principle just does not work when you apply it to healthcare. In fact, if you apply it too energetically, you provide perverse financial incentives to do absolutely the wrong things. I do not mean that there is no place for the market but I have always felt

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that a menu was better than a market-yes, there is choice, you make decisions and you understand that different approaches involve different costs; nevertheless, there is some kind of informed choice that is based not just on the cost but on the value of what you are trying to obtain for yourself or your patients.

Therefore, there is a limit to multidisciplinary teams that have no leadership; there is a limit to the notion of managerialism as the way to run a healthcare system; and there is a limit to the market as a model for running a healthcare system. Those are some of the things that we have learnt in healthcare over the past 10 or more years.

However, there are also a couple of major challenges that we need to address, one of which is the enormous change in the social patterns of the lives of the people with whom we are working. The noble Lord, Lord Rea, mentioned that we have an older population, and that brings with it increased challenges of all sorts-ethical and management problems and clinical difficulties. For example, certainly for a period of time, we were largely successful in getting rid of infectious diseases, and that let people live longer, so they lived longer in order to develop cardiovascular disorders. When you dealt with those, they then lived long enough to develop cancers of all kinds and, when you dealt with those, they then lived long enough to develop dementia. It is not as though when you deal with a whole set of problems they all go away. We live longer and experience other kinds of problems.

That does not mean that we give up but we have to be realistic that all sorts of changes need to be addressed. There are changes in social patterns, including the size of families, the type of family units and a range of people from all parts of the world with all sorts of different dietary backgrounds and physical backgrounds, infectious disorders, and so on. We have to deal with all those things. We have to be alert and aware of change, which is quite a challenge. As such patients come into your practice, whether it is a hospital or community practice, you have to become aware, if you were not before, of the complexities that they bring. That is not easy. There are cultural issues in dealing with patients that are very sensitive and difficult. It is not all about those in the community welcoming folk in from outside. It is not only about them understanding and changing; it is also about helping people who come in from outside to understand the community they are joining and the culture and requirements that that community has.

Those are challenges but there are also opportunities, many of which are provided particularly by information and communications technology. They change the way in which young people in particular-though not just them as many older people are increasingly adept at the use of information and communications technology-react to things, receive messages, relate to each other and the way in which we educate our clinicians. It is now possible to educate clinicians at a distance. For example, a skilled surgeon in one part of the country can assist someone conducting an operation on the other side of the world by using telemedicine. We can be in contact with patients in the community by staff using ICT.



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Some but not all of this is extremely successful. Just because you have a new gadget does not mean that it is better; just because something works faster it does not mean that it always works better. A colleague told me about a wonderful new system that he wanted to put in that would ensure that immediately the general practitioner made a referral it would be in my inbox. I said that it was no use whatever because the waiting list is still six weeks. It does not matter whether the referral comes in today, tomorrow or the day after, it will still be six weeks before the patient is seen.

Not every piece of technology or new gadget is appropriate, helpful or an effective use of resources. Some approaches can be extremely helpful in allowing us to move on and to learn the lessons about what actually works, which was the whole theme of the noble Lord's introductory speech. That is crucial but let us not dismiss the importance of research and academic work. It is not just about managerialism, although I do not dismiss that, as in a complex community management is extremely important. I have been encouraged by our new coalition Government's commitment to get decision-making and responsibility back to the patients, their families, the communities and clinicians of all kinds with whom they deal-it should not be held back at the centre whether that is a management centre, a Whitehall centre or even a governmental centre.

3.28 pm

Baroness Finlay of Llandaff: My Lords, I must declare an interest as a true Dr Finlay. I am a practising clinician; I am president of the Chartered Society of Physiotherapy; I work in palliative medicine; and I have links with many hospices around the UK. I hope that I have made all the declarations before I start.

We are facing change and I am sure that the Minister is inundated with advice and pressures but in the time preceding change, I hope that he will be cautious so that we do not have change while ignoring the potential unintended consequences of such change. One of the difficulties is that often we do not know what we do not know, and in the rush to bring about change we may not do the background research or explore the issues. I want to address the specialist services providing care for patients, the role of the third sector, particularly for terminal and palliative care, and the needs of patients out of hours.

In 2006, in England and Wales there were 503,000 deaths. That figure is anticipated to rise to 586,000 in 2030, which is a massive increase. Only about 20 per cent of patients die at home, so we have to think how the needs of all these patients will be accommodated. With that there has been pressure to move patients out into the community. The need for integrated care pathways for complex conditions increases as high levels of expertise are required to meet patient needs and there are more patients with complex conditions. I am concerned that in trying to save money substitution has been looked at but it is not without its dangers.

Despite a priority of providing care closer to home, the Audit Commission report, More for Less, found little evidence to show that PCTs have been successful in removing care from hospitals. There is little evidence

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that patients with rare, complex conditions are not prepared to travel to get expert care, because they know that they need accurate diagnosis and a really good management plan. The challenge is: how do we get patients seen by the right person at the right time in the right setting, as well as trying to move care out into the community? That is a stark cultural challenge that needs multiprofessional teams working in managed clinical networks to encourage collaboration and co-operation between primary, community and secondary care. That must also cover other aspects of home care provision, including social care.

The new commissioning arrangements must cross traditional NHS boundaries. The publication by the Royal Colleges of Physicians and General Practitioners, Teams without Walls, identified the need for integrated systems, clinical leadership in commissioning and aligned incentives, underpinned by patient involvement in commissioning systems, especially for those with long-term conditions.

The current problem is that payment-by-results tariffs in their present form incentivise against integrated care. The current tariff-based system encourages hospitals to treat more patients while, simultaneously, GPs are under pressure to refer fewer patients. That creates a tension that can work against the development of integration and against quality in patient care. It works against earlier diagnosis, particularly in recognising rarer and complex conditions. One way to rebalance the disincentive is to introduce payment by pathways or payment by conditions, to ensure that high quality generalist and specialist care have a sustainable future, for the benefit of patients.

Patients must enjoy equitable access to specialists when required. I have just chaired a joint report on allergies for the Royal Colleges of Physicians and Pathologists, and we have found a stark inequity in provision around the country. Specialist resources must be at the heart of any clinical network or community-based service. It is essential that we have services available 24/7. The current five-day provision does not meet patient needs. That service does not respond to the true, seven-day need of those who are really ill, including at night. In Wales, we have moved from five-day to seven-day working by clinical nurse specialists in palliative care, and we have shown in a short space of time a dramatic change, because problems that occur on Saturday will be dealt with on the Saturday or Sunday. By the Monday, it would have been too late to address them.

There are some specialist service needs where integration is essential. There needs to be a one-to-one relationship between the GP, the patient and the specialist in secondary care to ensure patient safety and that people understand the complexity of the patient's background. Repeated handovers do not work well. We know that information is being lost in a kind of conveyor-belt hand-over between clinicians. We need to restore patient safety and quality of care and ensure that the lead clinician has a comprehensive understanding of the patient to reduce complications and near misses, particularly in surgery.

Some things should be done only in places well equipped to do them. An increasing amount of so-called minor surgery has been done in general practice, but

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there have been some awful situations where melanomas have been removed, the margins have not been adequately marked, the resection was inadequate and the subsequent surgery was much more extensive and expensive than if it had been done in a specialist dermatology surgery centre at the outset. The Anaphylaxis Campaign has sent me horror stories of GPs giving advice to parents about children suspected of having a peanut allergy that was completely inappropriate and would have jeopardised the child's life, not just their health. It was just as well that the parents phoned the campaign with their anxiety.

There are real problems out there, and there are risks as well as opportunities in moving towards a largely GP-commissioned framework. Academic GP is essential to driving up the standard of evaluation. We need to evaluate patient outcomes in any change. This is not about having a fashion for one model or another; an evidence base must underpin commissioning. As PCTs are divested of their commissioning responsibilities, GP consortia are expected to take up the mantle, but their skills and background knowledge, and even their willingness to do this, are really deficient in some places.

There needs to be a national view on minimum access rates and the provision of highly expert services to avoid a postcode lottery, particularly where there is a low critical mass in a smaller population, otherwise you get a bidding war between GPs and consultants that works against quality. If you do not have adequate dual provision, community-based services will have fewer places to turn to for training specialists for the future, for continuing professional development and for research. Driving that forwards will drive up standards of care in the future, particularly for those with more complex conditions.

I ask the Minister to consider some specific things: that promoting the idea that engaging doctors in the spirit of collaboration is required for successful commissioning; that commercial loss leaders might appear at first sight to be useful but may lose expertise and undermine quality in the long term; that the repudiation of unhealthy forms of competition is essential, as is encouraging jointly commissioned models for integrated health services; that choice for patients means the ability to access specialist scientifically based clinical excellence to diagnose and plan their management, which can then go back for ongoing care in primary care if there are good pathways; and, lastly, that the incentives and disincentives of payments by result need to be rebalanced to bring integrated generalists and specialist care closer to the patient's home.

I am grateful to the noble Lord, Lord Alderdice, for flagging up the importance of the whole person and the whole family, because the third sector provides that par excellence in hospice care. There is a need to specify minimum levels of service, such as in hospice care, across the UK, and to have centrally agreed three-year contract with an agreement on how the service is delivered locally. At the moment, Marie Curie has to negotiate 200 separate contracts across the UK. That is a waste of time and a duplication of effort when models such as the fire service or the police demonstrate that you could have a national framework with local agreements on implementation.



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Hospice grant money has to be negotiated at a local level by small hospices that often do not have much expertise in negotiating with all the different people from whom their patients come. Competitive tendering is punitive to the third sector, because it does not have the resources to tender or the expertise of larger bodies. Punitive contracts in the third sector can really work against them. If they miss a level in their service they may incur a penalty, yet they provide a key service to the NHS.

Commissioning must become outcome-related, as much in hospice care as anywhere else. Currently, it seems to be process-related. It has to be integrated across the whole pathway, and this need to commission across the whole pathway means that the professional competency framework needs to be driven up to promote higher levels of competency. There is a real concern and a danger that private companies will come in and commission against a whole pathway, and one questions why they are needed as an intermediary. The danger is that increased income will go in profits to shareholders and not be reinvested in the not-for-profit third sector that the hospices epitomise.

In summary, there needs to be 24/7 provision, which should be addressed urgently. There is a large shortfall in district nursing. Only 53 per cent of PCTs have 24-hour district nursing, which is grossly inadequate if you are trying to care for critically ill patients at home. There has to be a closer link between health and social care. Care assistants can often be the key people to keeping patients at home.

On incentives, we should remember that healthcare professionals are proud. They want to deliver a good service. If you embed direct patient feedback into the system, as we have in Wales for palliative care using iWantGreatCare, it can become a powerful driver to quality improvement. One team does not want to perform less well than another, but patients need to provide feedback in an anonymised way so that they are not fearful that their comments might antagonise the clinicians looking after them.

There have been unintended outcomes from the current arrangements where financial incentives or punishments drive provision rather than need. Patients feel particularly lost out of hours and it is really important in commissioning healthcare that we get it right. There is a steady stream of horror stories coming through. It is not simple; it is not like shopping for shoes; and I hope that the Minister will think carefully about the unintended consequences of change.

3.40 pm

Lord Crisp: My Lords, I, too, congratulate my noble friend Lord Mawson on inviting us to reflect on primary care over the past 10 years and more. I know he is hopeful that his timing is such that the Government's policy is not yet so rigid that they cannot listen to new ideas and the practical lessons that he and others want to mention. I have to declare an interest. Most people know that I was chief executive of the NHS in England for six years. There is a lot that I could say, but I will concentrate on the same areas as my noble friend;

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namely, the integration of care, particularly thinking about social care, education and other boundaries around the whole person.


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