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The other day, an American friend said to me, "We love you in England because you keep changing the way you develop primary care. You are a wonderful laboratory. You have tried out lots of different ways of doing it". I guess that that is true. But I guess that there is a reason for that, which is not just a wish to meddle. It is that, as other noble Lords have mentioned, a lot has changed in the 70 years since the 1940s, when we set up the primary care system we have now. The three big changes have been referred to by others. The diseases are different. Seeing patients is much more about dealing with non-communicable diseases. They are about elderly people with complex or multiple problems. The patients have changed. They are much more demanding, but their behaviour is much more important in so many ways in terms of the management of care for diabetes or whatever. In addition, technology has changed. All those changes mean that our old model has led to shift. As we have noted, there have been many ways in which people have tried to make that shift. It is really important that we learn the lessons from those attempts to change and to make improvements.
Before this debate, the Royal College of Physicians wrote to me and, I suspect, to others saying that it was really important that we did not lose sight of the fact that primary care, secondary care and tertiary care need to join up. We need to have that all within the frame. It is interesting to reflect that the separation between primary care and secondary care is largely in legislation that is about 70 years old. It is not writ that a GP shall be this and a consultant shall be that. It was an organisational change. The way in which parts of the medical profession relate can change and some organisations, as I think that the noble Lord, Lord Alderdice, mentioned, employ or involve both. There is nothing rigid about this.
However, I want to talk about integration around the patient. Let me go back to the simple point that most patients today in richer countries are people whose needs often may be clinical, but alongside that there is a need for independence. I think that I have mentioned in this House before that my elderly father fell and broke an arm. Clinically, it was very easy to deal with, but the real issue was whether he could remain independent and live at home by himself. That is the sort of situation we are talking about in terms of many of the patients that the NHS deals with. Indeed, many patients with the highest expenditure in the NHS are those with complex problems that span clinical, social and other needs. So it is welcome to see primary care playing a major role in prevention and in helping patients find their way around the system.
Primary care is not just about GPs, and it is important to keep the two separate. There are different roles for many different people. One of the saddest pieces of research I have seen was published some years ago. It concerned young people suffering from depression and how they were treated in primary care and whether they were able to be taken seriously. There were too many accounts of people going to GP surgeries and being told to come back in three months if it was
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That takes me on to the issues raised by the noble Lord, Lord Mawson, about health and social care, and other areas such as health in education. He asked how far we should go to ensure that we have health provision in schools, whether in the form of health services or whether they are designed into the architecture of schools. He also asked if we should have local partnerships that are able to focus on what is needed. The noble Lord concentrated on social entrepreneurs, but I know that he, like me, is interested in how local partnerships made up of the right groups of people can have an enormous impact on a local environment in terms of health benefits and the related issues that go alongside them. By local partnerships, I am not just talking about individual organisations that bring health and social care together, but about partnerships that bring together everyone who has something to offer in this area. These can be quite difficult to conceptualise and describe in order to determine the policy that will promote them, so I would encourage the Government to look at some of the ones that work.
As I said, the noble Lord, Lord Mawson, referred to a number of social entrepreneurs and one or two exceptional GPs who have set up extraordinary practices that go way beyond what we would traditionally think of as healthcare. But I think that some of our PCTs have done exceptional things in trying to address inequalities, particularly in areas like mental health where we know that among the best things you can do for patients is help them to get jobs and housing. Among the range of entrepreneurial PCTs let me mention one particular group I know of and declare an interest in. Something like 20 UK PCTs are part of a group called Triple Aim. They are working alongside similar organisations in Scandinavia and the US, facilitated by an American organisation called the Institute for Healthcare Improvement. Here I declare my interest because I am working with the organisation in Africa rather than in this country. It would be interesting for the Minister and the Department of Health to look at what these PCTs are trying to do by taking on a triple aim-to improve the health of the population, improve the care given to individuals, and reduce costs. They are doing so by trying to integrate with local partners. There are some good examples that we can build on and, taking a completely different example, a number of schools in this country have health facilities within them. So I urge the Government to look not just at the social entrepreneurs referred to by the noble Lord, Lord Mawson, but at the organisational people working within the system who are trying to make these things work; they go very much together.
Finally, I come back to the issue of primary care trusts and GPs. I have seen some statements from the Government about giving GPs and doctors more control. I understand and appreciate that. One of the great merits of the NHS that shows up in any comparison with other systems around the world is its primary care. This is one of our great strengths, among others, and we must preserve it. But however wonderful some GPs are, not all of them are. They are not all capable of taking on all the roles that we might think we would
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Another issue in developing policy around GPs in the context of primary care is the potential for conflicts of interest, and again I suspect that the Department of Health has good examples of where, by putting more money into primary care decision-making hands, potentially and only in some areas you end up with conflicts of interest about how the money is spent. But-and it is a very big but-we have also seen great benefits from having primary care and GPs taking a lead. In particular, it is interesting that in a number of practices where the GPs have budgets and have taken a bigger lead around commissioning, they have changed the services they provide and the job roles of people. Increasingly you see people other than individual GPs when you attend a GP practice. That is all for the good, in both quality and cost terms.
I am reminded that 15 years ago we were trying to get more GPs into east London and tried to do so by recruiting salaried GPs-in other words, by moving away from the current model of GPs being self-employed. We were told we could never do that: it was not what GPs were about and it was essential that GPs were independent. I see the noble Lord, Lord Rea, nodding his head. However, we succeeded to some extent in making that happen but now it has all changed. Today, in practices where GPs are responsible for budgets and direct care, there are many salaried GPs and many people doing different kinds of jobs. That would not have been possible had you tried to make those changes from above. Indeed, GPs in London complain that they cannot get jobs as partners any more; there are now salaried jobs but the partnerships are being kept in fewer and fewer hands.
While that may be a downside, the important point is that doctors, as part of the entrepreneurial culture to which the noble Lord, Lord Mawson, referred, have the ability to make changes that mere managers, politicians and others from outside would find it difficult to make. It is important to build on that.
I hope that, like the noble Lord, Lord Mawson, the Government will look back on the years of change and development and learn the practical lessons. I should like to ask two specific questions. Will the Government look at innovative PCTs as well as innovative entrepreneurs, and perhaps consider Triple Aim as an example? How will the Minister clarify the relationship between PCTs and GPs in the future? I suspect this is one of the areas in which there is some confusion in the service at the moment over how primary care will be led, planning will be done and life will move on over the next few years.
3.53 pm
Baroness Emerton: My Lords, I, too, warmly congratulate my noble friend Lord Mawson on, first, introducing the debate but, more importantly, on demonstrating through his entrepreneurial approach
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We have had put before us lessons taught in managing change through people to provide a community service in every sense of the word. Like many other noble Lords, I found my visit to Bromley by Bow Centre a manifestation of real entrepreneurial skill- second to none in demonstrating holistic care in the most imaginative ways-which became not only productive in outcome but engaged the patients and community members in a non-conventional way. The emergence of a true community was evident. I found my noble friend's book very gripping, for no punches were spared in the description of both the barriers and the successes.
I declare an interest as a retired nurse. Over the past 10 years, much progress has been made in community services to encompass a wide range of services, including public health and prevention services, but despite many primary care and community initiatives we still have a long way to go on early identification of disease, risk factors, reduction of health inequalities and the promotion of child health. In the development of urgent care, acute care at home and end of life care services, community services work in close partnership with the GPs, hospital services and social services to support the independent living of older people and the safeguarding of vulnerable adults. They also work with children's trust partnerships. Currently, 200,000 staff are employed to meet these services, requiring £10 billion from the NHS budget. There is considerable evidence of widespread variation in productivity, which, if addressed, could generate a substantial direct improvement in service quality and sustainable efficiency, thereby reducing costs.
During the past 10 years, attempts had been made by the previous Administration to improve services through the recommendations in the NHS Plan, published in 2001, the general medical contracts in 2004, and the White Papers, Our Health, Our Care, Our Say in 2006 and Transforming Community Services, published last year. The Nursing and Midwifery Council, its regulator and its predecessor, the UKCC-of which I declare an interest as a former chair-have long supported the provision of healthcare in the community. During the previous decade, they introduced specialist community practice awards and created a specialist community health nursing part of the register. These measures acknowledged the shift in expertise needed to ensure safe community practice. While not yet enforced, the emerging standards for pre-nurse education will require pre-registration students to spend 50 per cent of training in practice-based settings, which will increasingly be within the community as services are reconfigured. This represents a sea change in nurse education and will herald a major improvement in healthcare delivery at the point of registration. The planned 4,200 increase in the number of health visitors is admirable. They play an important cross-professional, co-ordinating role, leading skill mix teams in delivery, postnatal, early-years and family healthcare.
However, it is important that health visitors retain a grounding in basic nursing and/or midwifery skills. Knowledge of diabetes, associated obesity, childhood
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The introduction of matrons, advanced practitioners, specialist nurses and consultant nurses in the community has resulted in many patients with complex, long-term conditions being expertly cared for without the need to frequent their local hospital. Community matrons in particular are striving to help people with long-term conditions become more self-reliant and better informed about their health and how to improve it. This reflects a shift in emphasis towards nurses helping to empower patients to look after themselves and manage their conditions better.
The programme to support practitioners to transform services and deliver high- quality care and productivity set out evidence for best-practice care within community services through a series of six transformational reference guides entitled, Health, Well-Being and Reducing Inequalities; Services for Children, Young People and Families; Acute Care Nearer to Home; People with Long-Term Conditions; Rehabilitation Services and End of Life Care. All of them provide a guide to high-impact changes and are intended to enable practitioners to give high-quality care.
The continuing work is looking particularly at the needs of frail, elderly patients with complex health conditions. They are the main service users of community healthcare and now occupy the majority of acute hospital beds. Increasing evidence points towards a wide variation in the care offered to the elderly. Studies indicate that up to 30 per cent of people in hospital at any one time, many of them frail and elderly, could be safely cared for in the community with the right access to community services and appropriate support. There are efforts to mobilise staff using evidence to create a "social movement" among front-line staff and empowering clinicians to lead change and innovation. This leads to the use of care pathways to increase care co-ordination and best practice for patients. Combining primary, community, hospital and social care to increase efficiency and provide high-quality care, it is best described as "care without walls".
At present, a high proportion of residential nursing homes employ healthcare support workers and social care workers. Evidence from a study conducted by Ian Kessler at Oxford University shows that many undertake aspects of care traditionally done by nurses but that they are not trained to do it safely. If there is to be an increase in community care, increasing the level of social carers and healthcare support workers, there must be an increase in safeguards on the roles undertaken by those staff. With no form of regulation in place, it is difficult to track and prevent those unable to provide safe levels of care. The move to community-based care poses a significant risk to patient safety.
Against a background of the demographic growth of the elderly population-requiring an increase in both long-term and acute home care-of the care of vulnerable children in pre- and post-natal care and of changes in the pattern of commissioning services, it
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The Royal College of Nursing continues to express its concern over the lack of investment made into the community nursing workforce. A particular concern is the problem of the ageing nursing workforce, as 27 per cent of nurses working in community services within the UK are aged over 50. Over the next 10 years around 180,000 nurses will be eligible for retirement, leaving a huge hole in the workforce which, at current levels of commissioning, will not be met by future recruits. There are concerns that the problem will be magnified through the current period of financial constraints by recruitment freezes and the deletion of posts as a result of efficiency savings. There has also been evidence of an active reduction in student places being commissioned, despite a record number of applications to enter the nursing profession. This, it says, is a great disappointment and a blow to all that has been done to improve the attractiveness of nursing as a career.
The leadership skills required are of paramount importance and it is through people rather than policies that change can be effected. The challenges of overcoming the barriers between various services are enormous but the opportunity to grow community services must not be lost. Just as my noble friend mentioned, it takes time to break through the barriers and that cannot be rushed. Certainly, in my experience of leading and managing a project relocating 1,500 and then a further 1,200 learning disability patients from two large hospitals, it took 10 years to ensure that every patient was individually assessed, relocated according to their needs and placed into the most appropriate accommodation. That involved seven London boroughs and two county councils-none of which was keen to take back its residents-while ensuring that staff were appropriately trained to care for residents in the community, which was completely different from being within the large hospital and a big culture change for them. There were relatives reluctant about their relatives transferring from the safe environment provided by the large hospital to an open community and there was the receiving communities' reluctance to receive learning disability clients.
While there was an overall strategy accompanied by a critical path analysis setting target dates, that project really required hours of careful negotiation through the barriers to result in a changed culture-one providing a more meaningful style of life for clients in a safe environment, while delivering high-quality care and management. Managing such an innovative project, as with those that we have heard described this afternoon, was certainly a huge learning curve for me-and, I am sure, for others. I believe that there is an urgent need for nurses and all healthcare professionals to gain the necessary leadership skills to be equipped to meet the challenges and opportunities of the future's reconfigured community services.
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4.04 pm
Baroness Thornton: My Lords, this is an interesting subject for debate, as the debate has proved. Learning the lessons of the past 10 years at the moment when great change is about to be unleashed on the whole way in which healthcare is delivered in the UK seems appropriate, and I congratulate the noble Lord, Lord Mawson, on his usual entrepreneurship in the timing of this debate and the passion that he brings to the issues of innovation in providing public services-in this case, healthcare-as well as his hopes for less bureaucracy, less political change but not, I hope, less accountability. The noble Lord has been making this kind of wonderful speech for as long as I have known him. Rightly, he blames bureaucracy and politicians in his passion to roll out the models that he knows so well and that work so well. As he knows, I have a great commitment to social enterprise and entrepreneurship, but I think that he needs to give some credit where it is due about the progress of the past 10 years.
I remind the House that some progress has been made. I should like to look at two issues-the LIFT programme and the development of social enterprise in the past 10 years. The LIFT programme, delivered through community health partnership, is there to create, invest in and deliver innovative ways in which to improve health and local authority services. I know that the noble Lord, Lord Mawson, is familiar with the LIFT programme and has tales to tell about the difficulties of this bit of the bureaucracy. But it is there to deliver and provide clean, modern, purpose-built premises for health and local authority services in England. The reason why the programme is so important is because 90 per cent of patient contact with the NHS occurs in general practice. The research shows that primary care in the inner cities, where healthcare need is the greatest, may have suffered from a disproportionately high number of substandard premises in primary healthcare. That is why we instituted the LIFT programme. We knew that the condition and functionality of existing primary care estate was variable, with current facilities not meeting patients' expectations and quality and access often being below an acceptable standard-and, therefore, service development sometimes very severely hampered by the limitations of the premises.
As a Government, we made an investment in primary and social healthcare facilities. We made it a priority in inner-city areas. It was clear to us that new buildings were required to provide people with modern, integrated primary care services. When we came to power, there is no doubt that the creation of new facilities was fragmented and piecemeal. Developments tended to be small scale and focused on more affluent areas; they tended not to integrate social care at all. The landscape has been transformed in the past 10 years. If I add to this the review done by my noble friend Lord Darzi, it is clear that we have made some progress.
I shall mention some of these outcomes and particularly draw them to the attention of the noble Lord, Lord Mawson. He said that he was tired of words and no delivery. Well, there has been a huge amount of delivery-in fact, £2.2 billion worth of delivery of new schemes. I take for example the centre at Church Road, Manor Park in Newham, which the noble Lord
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The one that I like best is the Kenton Resource Centre in Newcastle, which was built on the site of an old clinic on Hillsview Avenue. It has a new health facility, including the relocated GP practice, but it also includes community health professionals, Newcastle City Council and voluntary services, a local customer centre, which provides housing and benefit advice, a Newcastle City Council library, which serves three neighbouring districts, and a Northumbria Police office for local beat officers.
I could go on. In fact, the most recent centre was opened last week in Dudley-the new multimillion-pound state-of-the-art Brierley Hill centre. Therefore, I think that we can say that we have been delivering local community centres in the last 10 years, but I ask the Minister what the fate of the programme will be. How will it fare in the reconfiguration of the NHS that we are told is on its way?
Let us turn to social enterprise. I declare an interest as a serial offender in social enterprise. I have spoken many times in your Lordships' House about the development of social enterprise and I have sponsored things such as the community interest companies Bill. I think that it is worth saying for the record that social enterprise is a business whose objectives are primarily social and whose profits are reinvested back into its services for the community, with no financial commitments to shareholders or owners-it is free to use its surplus income to invest in its operations to make them as efficient and effective as possible. Well known social enterprises include Turning Point, the Eden Project and the Big Issue.
The Department of Health has been promoting social enterprises through the initiatives that the Labour Government took, as we saw the advantages of them for patients and service users. We instituted the right to request as part of our broader vision for the NHS. I know that the first phase of the right to request has been enacted and I think that the second phase is about to be enacted, but I should like confirmation of that from the Minister. I should like to know what will happen to the social enterprise investment fund and to the right to request.
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