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These decisions depend on services being integrated, not operating in isolation or in competition. They require excellence in clinical standards, not just "any willing provider". The problem is that private providers can cherry-pick services to provide in neat packages, but most patients do not fit neat packages. Choice in packages requires a surplus to choose from, but we cannot afford that. Those with complex co-morbidities are optimally managed by a service leading their care and collaborating with others, avoiding duplication and minimising the risk of patients falling into a gap.
How will secondary care integration with primary care be promoted and long-term planning secured? Patients want choice to be seen by the right person at the right time. Pathfinder consortia may be achieving this in the short term, but if Monitor is to ensure competition, how will such collaboration continue? To ensure data on fair competition, will commercial confidentiality clauses be overturned by statute? How will outcome data be collated? Will they be meaningfully interpreted to account for those with multiple co-morbidities?
I ask the Minister these questions because we are embarking on a reorganisation that will cost up to £3 billion. There is a genuine fear that an integrated NHS is being dismantled under the influence of for-profit organisations.
Baroness Greengross: My Lords, as chair of the All-Party Group on Dementia, I have a particular interest in dementia care. In my brief remarks, I wish to highlight the potential impact of the changes to those services.
People with dementia are major beneficiaries of effective joined-up working between health and social care. Can the Minister assure me that any changes in the current coterminosity of boundaries for commissioning health and social care will be appropriately managed for people with dementia?
One in three people over the age of 65 will die with dementia, and so for many it will be a terminal disease. Why, therefore, is dementia treated, rather than as a health issue like cancer, more as a social ill? In other words, it is more likely to get funding through social care. Thus many dementia patients are obliged to self-fund their care. Is something going to be done to remedy that?
With the implementation of the national dementia strategy we have witnessed the increasing knowledge and ability of many NHS managers in commissioning for dementia, which is absolutely essential. However, the number of people with these particular skills remains relatively small and it is a concern that the pace of structural change has the potential to undermine this
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Lastly, GPs will in future play an increasingly important role in commissioning services for people with dementia. However, I am concerned that many GPs have too little awareness or knowledge of dementia. For example, when surveyed, only 31 per cent of GPs believed that they had received sufficient basic and post-qualification training to diagnose and manage dementia and only 47 per cent of GPs said that they had sufficient training in dementia management. Only one-third of people receive a formal diagnosis of dementia. What will be done to ensure that GPs are fully capable of discharging their new commissioning responsibilities with regard to this absolutely urgent situation? I hope that the noble Earl can respond.
Lord Touhig: My Lords, I am pleased to be here for this debate, if only to have listened to the speech of the noble Baroness, Lady Jolly, because she spoke from the heart about the National Health Service and her family's personal understanding of and reception by the NHS recently. She was also able to speak with some authority as someone who has been involved in the provision of healthcare. I look forward to her future contributions on this matter.
If you are a man who has had a stroke and as a result you have no recollection of the wife you have been married to for 30 years, and then you develop dementia, you have no voice. If you are a woman who one day stops talking to her family and has not spoken a word in 18 months, retreating into a valley of silence, you have no voice. If you are a dementia sufferer who is doubly incontinent and you have no downstairs shower and toilet, and the only day of the week when you can be sure that you will be made really clean is the day you go to a healthcare centre, you have no voice. As Parliament, at the behest of the Government, prepares for a major shake-up in the provision of NHS services, I believe that we must be the voice for dementia sufferers and their carers.
Three-quarters of a million of our fellow citizens have dementia and it is forecast that by 2025 the number will be over a million. I welcome the success of my noble friend Lord Turnberg in securing this debate so we can press the Government to tell us how front-line specialist services will be protected in this shake-up. We currently spend £20 billion a year on dementia and, as the noble Baroness, Lady Greengross, pointed out, one in three people over the age of 65 will die with dementia-yet currently only one in three receives a formal diagnosis. As a member of the Public Accounts Committee in the other place, I well remember a National Audit Office report in 2007 which found that money was being wasted on poor quality care. The report went on to say that rates of diagnosis were low, cost-effective interventions were not widely available, and health and social services were often disjointed
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I share the worries of the Alzheimer's Society, which is concerned that the pace of structural change that is going to come in the NHS has the potential to undermine the progress we have made so far. That is all the more reason why these changes, as the noble Baroness, Lady Greengross, said, have to be managed very carefully indeed. When I was a Minister in the previous Government, I well remember the former Prime Minister, Tony Blair, saying to me that for him healthcare was not about the doctor, the nurse or the latest high-tech scanner, it was about the patient. Of course, he said, we need the doctor, the nurse and the high-tech scanner, but the focus the whole time must be on the patient-and that, I believe, is right.
Over the past couple of years, we have seen increasing knowledge and ability among many NHS commissioning managers in commissioning better and improved care for dementia. However, the number of people with these particular skills is relatively small. It is vital, therefore, that the pace of structural change which will come about as a result of the Government's NHS changes does not undermine this progress. Valuable dementia commissioning has been developed and must be retained. Perhaps the Minister can say something about this. GP commissioning will play a major role in the future, but only 31 per cent of GPs believe they have received sufficient basic and post-qualification training to diagnose and manage dementia. Can the Minister say what specific steps the Government will take to ensure that the small pool of dementia care commissioning expertise is not lost, a point well made by the noble Baroness, Lady Greengross?
A recent survey showed that only 5 per cent of GPs had discussed the national dementia strategy with their PCT commissioners. What is important, therefore, is that the current coterminosity of boundaries for commissioning health and social care is not lost. People with dementia are major beneficiaries of effective joined-up working between the NHS and social care because they use the two services. In order to continue to meet the needs of people with dementia and their carers, can the Minister assure us that the new GP commissioning arrangements will result in a comprehensive primary care response, including improved home care, so that admission to the acute sector is used only where it is necessary?
We can only imagine what it must be like to suffer with dementia. A dementia sufferer is like a prisoner locked away by an illness of the mind in a world of their own. That is why we must be the voice for those people and their carers.
Lord Kakkar: My Lords, like other noble Lords, I first congratulate the noble Lord, Lord Turnberg, on having secured this important debate and the noble
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The question posed by the noble Lord in this debate is an important one. He asks what steps are currently being taken to ensure that front-line and specialist services are not undermined as we move towards the changes proposed in the forthcoming health Bill. Healthcare systems around the world, particularly mature healthcare systems, are all focusing on the need to improve quality and value, so that the very best clinical outcomes can be achieved for our patients and that these can be achieved in the most effective and cost-efficient fashion so that the valuable resources that the state provides for healthcare are used for the maximum benefit of all in society.
In that regard, there are four important actions that might be considered in the interim between now and when any changes that are finally agreed when the health Bill passes through this Parliament come into force. The first is in the area of the education of general practitioners and other clinicians in primary care who will have to play a greater role in commissioning. At the moment, there is no specific training for the skills that will be required to ensure that, at the very least, they can supervise and provide the appropriate governance for any commissioning taking place in the environments where they have responsibility in primary care. I ask the noble Earl what arrangements are being made currently to ensure that programmes of continuing professional development start to come into place to provide the skills to those working in general practice to prepare them for the new responsibilities that they will inevitably have if practice-based commissioning goes forward.
The second is an area that the noble Lord, Lord Turnberg, has alluded to-the whole question of integrated care pathways. These are important. In ensuring that we maximise quality and value in healthcare systems, it is well recognised that a focus on integrated care pathways, particularly for chronic diseases, will be essential. To ensure that we can provide the opportunity for informed commissioning of these services, we need to be certain that metrics that can be used to determine whether the clinical outcomes are successful and are providing best value are developed, assessed and then are available for those who will take commissioning decisions in the future. What arrangements are being made currently to start developing models of integrated care, particularly for chronic diseases? What work is being done to determine the appropriate outcome measures and metrics that might be used to drive commissioning decisions in the future?
The third area is one of specialist services and in particular the important question that has been raised about the tariffs and the current difference in costs for the provision of specialist services. With the move for responsibility for specialist commissioning to the NHS Commissioning Board, is work currently being undertaken to provide clear definitions of what specialist services will be in the future? For those delivered at regional or supra regional level, what will be expected of these specialist services? Is work being undertaken to determine
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Finally, I turn to the issue of clinical leadership, one that I have spoken about previously in your Lordships' House. There is no doubt that that this is a major programme of change. It is often said that it is only those who deliver the service who can change the service. Our healthcare professionals, be they doctors, nurses or other healthcare professionals, will not be managed into this change: they will need to be led into it. Winston Churchill said some 60 years ago in a famous speech:
I strongly believe that if we give our healthcare professionals effective clinical leadership, they will indeed deliver for us the change agenda of improving quality and value as well as these changes and those that the previous Government quite rightly focused on, so that we can continue to enjoy a National Health Service of which we are all proud, which delivers the very best healthcare for the people of our country.
Lord Crisp: My Lords, I am grateful to the noble Lord, Lord Turnberg, for giving us an early run at one of the key questions coming out from the Government's proposals-a question which I might rephrase as: will they work where it really matters, at the front line? I, too, congratulate the noble Baroness, Lady Jolly, for giving us such an eloquent description of why they matter.
There is a great deal to be said for the Government's proposals-not least the continuation of a 20-plus year policy for a primary care-led NHS and for decentralisation, although, as some noble Lords have pointed out, there need to be limits to both of those. There are of course risks. It will be no surprise that I shall concentrate on the more managerial issues. The Minister knows, but I should say for the record, that I was chief executive of the NHS and Permanent Secretary of the Department of Health for six years; so I am afraid that I know a bit about reorganisations and may be seen by some of my clinical friends in the House as one of the villains of the piece.
I read the Command Paper that came out before Christmas with great interest, particularly where it talked about how to manage the transition. It was well written, as I would expect from former colleagues in the Department of Health, but there were some fundamental gaps that are fundamental risks. I will mention three of them.
The first is the capability of consortia. I have no doubt that there any many good, talented and skilled GPs and people working in primary care who can and will take the lead in this area. I did not find anything in the paper that described how the capabilities of those consortia to discharge that role would be in any way tested. Your Lordships will no doubt know that foundation trusts and NHS trusts go through a critical scrutiny as to whether they are capable of discharging their functions, and that is to be continued under these proposals. As
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Secondly, as a subset of that, I was again interested to know how consortia would be accountable. I see in the text that there is somebody called an accounting officer who is not really defined other than as the person who will account to the NHS commissioning board and then upwards to Parliament for the expenditure of the consortium. It need not be a doctor, we understand, but there is a question about what their responsibilities and powers are. In some ways it looks like going back to the old system of consensus management that we had 25 years ago where you basically had a doctor and an administrator in charge and you had to get the two of them to agree to get any change going. This was the sort of situation of which Roy Griffiths, in a report for the Conservative Government of the 1980s, said that, were Florence Nightingale back today, she would be wandering the corridors of the hospital wondering who was in charge. That question is still there. How will that arrangement work for accountability?
The third gap, to which my noble friend Lady Finlay alluded, is that these consortia will turn for expertise to private sector organisations, some of which will be from abroad. We know that GPs are saying that, and that it is already happening. They will, for example, turn to people with experience in insurance systems. We have a social contract system: we expect to be able to go to our doctor and know that they will do their best for us, looking at a comprehensive care with some exceptions rather than an insurance system that too often specifies what you can have. There is a big difference between the two. My worry is that there will be a change in the attitude of mind and behaviour in that relationship.
I have one positive suggestion here which the Minister may or may not like. Although there are pathfinders and there is preparation under way, I have not seen anything that suggests there will be any large-scale simulation of these proposals-getting people together and, over a period, encouraging them to play out the various roles to see what will happen. That has been done in the past, and it is an effective way. The question need not be whether these proposals will work but what you need to do to make sure they work as effectively as possible. Can the noble Earl say whether the Government propose to do any such simulation of these proposals before bringing them fully into effect?
Baroness Meacher: My Lords, I, too, applaud the noble Lord, Lord Turnberg, for initiating this debate. I am sorry that I was not aware of it until rather late in
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My second example is local. I am not in any way suggesting criticism of the organisation or individuals concerned, but the commissioning changes are already inevitably distracting managers from their day-to-day essential decisions, again with severe adverse consequences. A particular trust with which I am associated, and I declare an interest, has to cut its budget by 4 per cent each year for three years-by £10 million a year. To achieve that, two very significant rationalisations were evaluated and planned, but the PCT's approval is essential before we can go ahead. If those vital savings are delayed-and they are being delayed, as we will not have the PCT decision in time-then we will have to turn away from those well planned changes. The risk is that we will have to make quick cuts on front-line services. Those are my concerns about organisational change and its direct impact on front-line services.
Baroness Meacher: Two minutes? I am sorry; nobody warned me about the two minutes. I will very quickly raise the questions. The first is about the power to determine whether a specific drug or treatment may be given under the NHS-I am now completely thrown, but there is a concern about the loss of that power of NICE. The second question concerns the role of Monitor as the regulator and the removal of its compliance framework under the new proposals, as I understand them. It is an excellent provision under the old system, which we are going to lose. I have concerns about that and look forward to the Minister's response.
Baroness Thornton: My Lords, I congratulate my noble friend Lord Turnberg on this debate. Indeed, of all the speakers who have contributed today I particularly welcome the noble Baroness, Lady Jolly, to our debates and our deliberations for the future. I also need to congratulate all the speakers who have contributed today, because we have had a really excellent debate. We probably needed about two or three hours longer than we have had; maybe we need to do that.
I want to raise two matters, one strategic and one specific. Since June we have debated or had Questions on, among other things, cancer, diabetes, chronic pain, Parkinson's disease, epilepsy, social care, COPD, neurological conditions, dementia and many others. I cannot recall a single debate or Starred Question where the issue of how services would be either safeguarded or delivered under the proposed reforms of the NHS was not raised in one way or another. The Conservative-led Government have been telling us this comforting notion that your family doctor will commission the services that you need-and who better to do so? I am on the record as saying that I support that in principle. However, Conservative MP Sarah Wollaston rather let the cat out of the bag when she wrote in the Guardian on 4 January:
"I know many GPs who are keen to tackle the redesign of care and even the issue of failing colleagues, but I know none that are interested in EU competition law. If commissioners cannot design care pathways free from the spectre of lawsuits from private providers, they will hand over to commercial commissioners prepared to take the rap".
I think that that means that private commissioners may turn to private providers at the expense of NHS providers because of the intimidation, or their interpretation, of EU competition law. Will the Minister confirm the role that EU competition law will play in the forthcoming reforms? For example, will GP commissioners be able to choose NHS providers where they offer the best quality and comprehensive service even if they are not the cheapest, without fear of legal challenge from private enterprise cherry-picking the most lucrative contracts? The Minister will know that I have long been a supporter of choice and diversity within the NHS, but the question of how we achieve that might lead to a fundamental dividing line opening up between us.
The EU competition rules being used as a regulator for NHS services through Monitor provide us with a huge problem. The problem, if I might put it in shorthand, is that health-providing companies owned by shareholders and hedge funds are not independent providers; they are accountable to owners who want to see a profit. So patients and organisations that promote the interests of long-term conditions, for example, are correct to be asking how health services owned and run by these people will have their long-term interests at heart. These are the questions that we will need to answer when we look at the NHS Bill that is promised next week.
What role does the Minister envisage for the market, for competition and for the private sector as a result of these proposed reforms? Does he believe that collaboration or competition is the best way to run our health service? I promise noble Lords that the noble Baroness, Lady Finlay, and I have not collaborated in asking that question. These are very big issues to which, as I have said, I suspect we need to return for longer and deeper consideration.
I conclude by raising a specific issue-in many ways, a perfect example of the anxieties that are being raised in all quarters. This concerns GP commissioning and the future of cancer expertise in the new system, and I thank both Cancer Research UK and Macmillan Cancer Support for drawing this to my attention.
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As the Minister will know, the cancer networks have been an absolutely integral and important tool in improving outcomes for cancer patients. The Government have said in the new cancer strategy, Improving Outcomes: A Strategy for Cancer, published yesterday, that cancer networks will continue to be funded during the transition period to GP commissioning. How will GP consortia make use of the expertise currently available in cancer networks to help in the effective commissioning of high-quality and seamless cancer services? How will the Government ensure that the functions currently provided by networks are not lost and standards compromised under the new commissioning regime? Will the Government ensure that cancer networks are funded throughout the transition period until 2014? Will that funding include funding that cancer networks receive from PCTs at the moment as well as directly from the Department of Health? How will GP consortia be incentivised to ensure that the critical functions of cancer networks are still carried out as they commission cancer services?
I am happy if the Minister wants to write to me about those questions; it is unfair to expect him to answer them in detail at this moment. But they are very important, and I look forward to his remarks.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe): My Lords, this has been a wide-ranging and well informed debate. I thank the noble Lord, Lord Turnberg, for calling it and all noble Lords who have spoken so eloquently. It is particularly right that I should single out for special praise my noble friend Lady Jolly, who I am delighted to welcome to your Lordships' House and our health debates.
The wording of the question that we are debating hints at some nervousness about the Government's reform proposals. I understand and appreciate many of the concerns that have been articulated today. There is, however, one simple truth about the reforms: they are necessary to create a sustainable NHS for the future. To make efficiency savings you have to improve commissioning and address the long-standing problems in a minority of challenged providers. It is for the long-term as well as the short-term future of the health service that we are working, and I remain exceedingly optimistic about that future.
The Government are fully committed to the NHS and its values and principles. We have prioritised its budget. Total health funding will rise by more than 10 per cent over the spending period. We are also starting to cut spend on administration to focus funding on the front line. The right reverend Prelate voiced some perfectly legitimate concerns about implementing change at a time of financial challenge. I agree with him that the future will see a great deal of change for the NHS. We are not shying away from the difficulties this will present, even within a protected budget. Increasing
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Our reform agenda is entirely focused on improving the quality of healthcare services. Our vision is to improve health outcomes so that they are among the best in the world, and to bring about a genuine shift in power away from the state and towards the front-line staff and the people who use services. The reforms are designed to lead to better quality and more consistent commissioning so that outcomes for patients improve; drive up the quality of care through patient empowerment and choice; give providers greater freedom to innovate; and create a level playing field with fair pricing, encouraging services to be more responsive to patients' needs.
There is a clear focus on quality throughout our reforms. To name but a few, there will be payment incentives for quality through the Quality and Outcomes Framework, CQUIN and the tariff. Under the health and social care Bill, which will be introduced shortly, the Secretary of State, the NHS commissioning board and GP consortia will also be required to act with a view to securing continuous quality improvement in services provided by the NHS.
To achieve optimum outcomes for patients, we are transforming how quality is measured and how the NHS is held to account, shifting the focus away from centrally driven process targets towards improved outcomes, with the NHS held to account against a new NHS outcomes framework. Patient choice is not an end in itself but the focus on choice will drive up the quality of services and therefore improve outcomes. There will be greater access to information and-not least for chronic disease, which was mentioned by the noble Lord, Lord Kakkar-patients should have a greater feeling of empowerment.
The noble Baroness, Lady Masham, focused on specialised services, particularly for spinal injury. I will write to her on the detail of her questions. We recognised the needs of patients for specialised services when we drew up the reform programme last summer. Patients accessing specialised services should receive high-quality, effective, evidence-based treatment and care with improved outcomes. Our proposal is that the NHS commissioning board should commission specialised services. Responses to the public consultation have generally supported this proposal. However, the system will allow for flexibility in who commissions which services, allowing for changes over time as needed.
The noble Lord, Lord Kakkar, asked me about definitions. There will be the flexibility to change the definition of specialised services so that more or fewer services are commissioned by the board. This will allow the system to align with changing patterns of care. Additionally, there will be flexibility for consortia to decide how to commission other low-volume services; for example, by federating together.
The key point here is that we recognise that there is no one-size-fits-all organisational structure that will work for all services equally. Therefore, we are moving away from specifying a fixed number of local or regional commissioning bodies to create a much more
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The noble Lord, Lord Turnberg, asked me some specific questions about whether there were to be any cuts in the number of trainee doctors. The number of trainee doctors should be appropriate to meet the estimates of future demand for trained doctors. This year the entry to postgraduate medical training will be around 6,800 in total. That is in line with the recommendations from the Centre for Workforce Intelligence report on 2011 training numbers that analysed trainee doctor intakes in the context of long-term demand for consultants. The Centre for Workforce Intelligence will continue to provide that kind of analysis to us. The noble Lord asked about GP pathfinders. We are engaging with the first group of pathfinders to consider some of the very questions that he posed. We will be hosting a learning event for pathfinders later this month to explore those issues and to showcase the early impact of emerging consortia. It will be the responsibility of the NHS commissioning board to produce and publish an analysis of the findings of the pathfinder programme and set out the lessons learnt but we are also setting up a learning network to ensure that the experience of pathfinders can be quickly shared through the wider GP community. The learning from the pathfinders will touch on both the areas that the noble Lord raised. One will be to look at some of the structural principles such as the successes and obstacles that consortia of different sizes come up against. But we want pathfinders to start making a difference for their patients now, and so improving services for patients is the area into which pathfinders will be putting most of their efforts.
The noble Lord also raised the issue of integrating care and the spread of good practice and how that will be incorporated into contracts. One of the key roles of the board will be to provide national leadership for driving up the quality of care. I say that also to the noble Baroness, Lady Sharp, who asked me about this. It will help spread best practice by publishing commissioning guidance and model care pathways based on the evidence-based quality standards that it has asked NICE to develop. It will develop model contracts and standard contractual terms for providers. It will also develop the commissioning outcomes framework. I could go on about more areas of support that consortia will get from the board but I hope this reassures the noble Lord that our reforms will mean that good practice is embedded far more widely and more quickly than it is in the current system.
The noble Lord asked how the expertise and knowledge of clinicians in secondary care would be built into this process. That was an issue raised also by the noble Baroness, Lady Sharp, and, in a different way, by the noble Lord, Lord Touhig, in relation to dementia care.
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The noble Baroness, Lady Sharp, asked me how health and local government services will be joined up. For the first time local authorities will have a lead role in improving the strategic co-ordination of commissioning across the NHS, social care and related children's and public health services. The new health and well-being boards will bring together the key leaders across these services to work in partnership and to develop a joint health and well-being strategy for their area. I hope that that partly reassures her that the services she particularly mentioned will certainly not be lost sight of in that process, because there is a fundamental synergy in the structures that I have referred to.
The noble Lord, Lord Turnberg, asked what is to happen to OSCHR, the Office for Strategic Co-ordination of Health Research. It has done a fine job over the past three years. It is a very useful mechanism for facilitating processes for joint working, focusing particularly on translational research. That body will continue with an increased focus on co-ordination and foresight.
The noble Lord also asked how GP consortia will be incentivised to be involved in health research. I recognise his concerns. There is not time for me to say a lot, but the department is funding the National Institute for Health Research Primary Care Research Network. This brings together a wide range of primary care health professionals and is dedicated to expanding clinical research in primary care. The Academy of Medical Science's report, which the noble Lord referred to, was published this week. We welcome the report and we are carefully considering how to implement its recommendations. I will write to him further on that.
The noble Lord, Lord Winston, asked in particular about how academic medicine will be protected. The Government recognise the crucial importance of academic medicine; we are increasing funding for health research, as has been mentioned, part of which supports lectureships and other awards, and we are currently consulting on our proposals for education and training. However, again, perhaps I may write to the noble Lord with further and better particulars.
My noble friend Lord Colwyn spoke on his specialist subject of dentistry, and perhaps I can make some amends for my previous omissions on this score. The Government are committed to piloting the new contracts before introducing any of them at scale, to ensure that lessons are learnt and acted on. The design and introduction of a new contract will be a key part of the piloting process. The BDA has welcomed that. Representatives from the profession have been closely involved in the work to develop our proposals. The
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On herbal medicine and the possible regulation of authorised practitioners, I cannot go much further than I did in my earlier Answer to the noble Lord, Lord Pearson, other than to acknowledge my noble friend's rightful concerns and to re-emphasise that we are taking our deliberations forward as a matter of urgency.
The noble Baroness, Lady Sharp, asked who will oversee hospital expenditure. The answer is that that will be done by governors in foundation trusts, who will scrutinise trust board expenditure. She also asked me about NICE, as did the noble Baroness, Lady Meacher. NICE is recognised as an international leader in the evaluation of drugs and health technologies and will continue to have an important advisory role, including assessing the incremental therapeutic benefits of new medicines. However, as we implement our plans for value-based pricing from 2014-a little way ahead-NICE's role will inevitably evolve. Its work will increasingly focus on giving authoritative advice to clinicians on how to deliver the most effective treatments and on the development of quality standards.
I am conscious that I have overshot my time. Although there is technically time in hand, it would not be courteous to the House if I continued. I have many further answers and I apologise to noble Lords whose questions I have not reached. I will write to them as fully as I can. I apologise in particular to the noble Baroness, Lady Finlay, whose questions I was very keen to answer.
I recognise that these reforms will be undertaken in a challenging context in which staff and leaders across the NHS face personal and professional uncertainty about their futures. However, the enthusiasm shown by commissioners, providers, managers and clinicians to bring the new system into being makes me certain that success is achievable.
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