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An ageing population and the increasing use of healthcare in the BRIC countries means that the industry has huge growth potential. Countries such as the USA, Singapore and France have recognised this by increasing their investment in research capabilities. We have strong research universities in life sciences, as evidenced by the high citation impact, which beat even the United States of America. But we underexploit the resources that we have-the NHS, universities, and large and small pharma.
While strong institutions, enabling regulations, funding and people with research skills are important, what is lacking across the country is collaborative mechanisms, and the fora, incentives and metrics that promote and encourage interactions between the players. Collaboration allows a better use of resources, avoids duplication and improves access to specialist facilities and expertise, which importantly improves the capacity for innovation. Big pharma is increasingly looking for external partners for drug development. Industry currently funds around 10 per cent of biomedical research in UK universities. If universities were to increase this to 15 per cent, it would mean an extra £100 million, which still would be only 8.5 per cent of extramural R&D funding of pharma companies.
There is a risk that the UK will remain static while other countries grow. One indicator of the extent of such collaboration could be an analysis of the levels of clinical trials activity in each hospital trust. Currently, the number of patients enrolled in clinical trials is low and falling. Collaboration would produce company growth in the private sector and increase income in the public sector. As pharma grows, R&D spend will grow. By 2015, there could be an additional £3 billion in external R&D funding. We need the right infrastructure, an electronic patient record system to support research and reform of the VAT system to encourage collaboration, and to develop more specialist support services.
The UK should accelerate the development of electronic patient records to support medical research and aim to become the world leader. Scotland has made a success of this and provides a valuable research resource. Industry can help by providing more industry
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I hope the Minister agrees that in our world-leading pharma, leading research universities and the NHS, we have fantastic opportunities to bring about innovation and treatment of disease. The Government should examine ways to see how best to bring this about.
Lord Haskel: My Lords, first, I congratulate my noble friend on this debate. I should also like to commend the Minister for his perseverance. This is the third Thursday on which he has been on that Bench. I am very pleased that this debate has moved on and that we have not heard a lot of speeches which continuously tell us that all our troubles have been down to the previous Government.
I agree with my noble friend Lord Hollick that the Government's paper, The Plan for Growth, has many hopes and aspirations. Who of us does not support balance in the economy and growth in manufacturing, investment, skills and science and technology? We all share, and have shared, these aspirations for many years. When I talk to people in business today and ask them what they consider to be the most important factor for their future prospects, the answer is not tax, regulation, or the five things that the Government list in their paper. It is people such as those who my noble friend Lord Hollick listed and the noble Lord, Lord Hamilton, spoke about; as a Jewish immigrant, I thank him for his words. It is not people who are anxious to avoid tax. As my noble friend Lord Kestenbaum said, it is people who want to be part of a national effort to build our economy. But this topic is entirely absent from this paper. It is the modern style of outward-looking, entrepreneurial people-based management which seems to be the hallmark of most new successful businesses, about which my noble friend Lord Mitchell spoke.
The noble Viscount, Lord Eccles, spoke about government grants. Yes, the Government do try but their finance is available in small packets for specific purposes. Schemes are announced all the time. One such scheme, announced in May 2010, was a tax break for the first 10 employees of a new business set up in Britain's poorer regions This scheme received special mention in the Economist on 3 March. A government source described the take-up as "incredibly low". It was incredibly low not because of bureaucracy but because this fragmented attitude no longer works. Trying to tease out individual causes does not seem to work any more. Businessmen have to bring it all together. At the end of the day, you either have confidence in the people and the project or you do not. As everyone knows, it is people who matter, which is where our priority should lie.
Lord Birt: My Lords, the UK economy in London and the south-east is measurably as productive as any in Europe, not just because of the City's world-leading
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In the UK, we look increasingly to the global labour market for rare and valuable skills. Overall, our own education system focuses insufficiently on the need to arm individuals and to provide the UK economy with the skills needed at every level to power modern business. For decades, our high-level educational outcomes have lagged behind our competitors, and that needs to change. Moreover, overly rigid immigration rules will block the entry of vital skills and talent, and thus threaten our productivity even further. So too, amid the realities of the global economy which I daily live and breathe, will internationally uncompetitive tax regimes for individuals and corporations. High tax rates will not prompt an immediate exodus, but I have seen at the margin the impact they have, and it is adverse to our true national interests. I should declare my own interests as a director or shareholder of several companies operating both nationally and globally; these are listed in the register.
Other factors are reducing our productivity. The principles that underpin the UK's planning regime are admirable, but the interminable length of many of our planning processes and the fact that there is no economic penalty for all those who can cause delay-often very considerable delay, and many of them from the public sector-is enormously value-destructive. Our economy is also handicapped by the worst transport infrastructure by far in the developed world. The individual who wrote in a recent business department paper that the UK has a "well developed infrastructure network" should be sent immediately to Holland, where I was last week, to compare, for instance, the superb Dutch road and airport infrastructure with the UK's own. Perhaps the Chancellor, when next contemplating his admirable aims for promoting UK productivity might reflect, when travelling to his own constituency in the north-west on the M6, that it is Europe's worst and most congested strategic route, and then remind himself of the trivial investment in current spending plans for improving our national road infrastructure.
In conclusion, if we are ever to bring productivity in the UK up to world standards, the Government will need to roll up their sleeves and focus on getting the big things right, on addressing the stubborn, difficult
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Lord Layard: My Lords, long-term growth depends on the accumulation of capital. I want to make just one point about each type of capital: human capital, physical capital and social capital. Human capital is of course much the most important as it accounts for over half of the value-added in our economy. As a country we do quite well at the production of human capital in our universities and sixth forms. We have a good and well understood system. But we have absolutely no well understood system for producing skills for the other half of the population. It is an area of scandalous neglect which has persisted for many decades.
Eventually, the previous Government produced what I consider to be the central solution, which is to ensure that everyone who wants it can have access to an apprenticeship. This was established as an entitlement in the Act passed in 2009. Anyone with five passes of any kind at GCSE would be entitled to an apprenticeship place. As a result, every 14 year-old would be just as likely to see a way forward if he wanted to go down the apprenticeship route as he would if he took the sixth form route. This was to happen by 2013 and in my view it was the single most important policy for growth that was introduced in the previous Parliament. But, incredibly, the present Government's Education Bill, if it is passed, will cancel this reform. Instead, the Government are offering 12,500 extra places a year for unemployed youngsters. One wonders at their thinking. How can it make sense to wait for a person to become unemployed before they can get a proper education? We have got into an extraordinary frame of mind in this country. For that group of people we have stop-gap measures and programmes. We want a proper system for the half of our population whose talents we have failed to develop to enable them to become skilled and have a proper stake in our community. Will the Government please let the reform in the 2009 Act stand? They did not oppose it before, and surely the need is even more obvious now.
I turn to physical capital. What we need are incentives to invest, which means good prospects for growth and financial inducements for the creation of new capital. But instead the Government are spending money on cutting corporation tax, which mainly provides a windfall gain for existing capital. If we had time-limited tax allowances for new capital creation, that would be of benefit in the long term and bring forward the recovery.
Finally, social capital is a much neglected asset of ours, but it is crucial to the mobilisation of our human potential. Social capital is what the big society is all about, so I find it difficult to understand why we are seeing the destruction of so much social capital at this time. Every day we hear of people in the third sector being laid off. They are often people who have been mobilising the assets of dozens of volunteers. We learn from the National Council for Voluntary Organisations that the charitable sector is annually going to be losing at least £3 billion of state funding. If
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Lord Flight: My Lords, first, I congratulate the noble Lord, Lord Hollick, on initiating what I think has been a very constructive debate. I also congratulate all the maiden speakers on their excellent contributions. I feel passionately that this country should do better. I am a lover of its history and I observe what has happened in the past: how self-help, a strong work ethic and a dissenting culture got industry and commerce going in this country. We have had interesting contributions today from the noble Lords, Lord Kestenbaum and Lord Popat, on the importance of the entrepreneurs from the immigrant communities. In the past, it would have been Huguenots and others.
I do not think that there is perhaps such agreement on the conditions that are likely to see us doing much better and that saw us doing so well in the past. I am no apologist for it, but I think that they are essentially to be found in capitalism. I have lived and worked in Hong Kong and I have been a great follower and lover of India. I observe how both of them, India latterly, have done so incredibly well. Living standards in Hong Kong are now much higher than here as the result of a much more open capitalist economy where entrepreneurs can prosper. In my textbook, if the public sector is much more than 40 per cent, you are heading for trouble, and in my textbook, if small businesses are tied down by too many regulations, they will not prosper. I was particularly interested in the speech made by the noble Lord, Lord Mitchell, about Brick Lane. Indeed, that is exactly the sort of entrepreneurial new area colony we want to see. I am glad it has happened, but I think it has more to do with good luck than a perfect environment.
I do not believe that any government-contrived go-for-growth policy will work. The Heath Government tried it and it ended in disaster. Governments can make the right environment for the economy to do better, and this Government are doing pretty well at it, but there are no government quick fixes.
Productivity growth in the past decade fell by 25 per cent, from 2 per cent to 1.5 per cent per annum. I regret to comment that it was very obviously the result of the overexpansion of, and negative growth in, the public sector. The poor old private sector was having to run faster and faster and was being squeezed by resources going to the public sector. The coalition Government have got things pretty well right. On the whole macro issue of keeping our credit-worthiness, they have succeeded. I would have liked there to have been no increases in tax-if anything, tax cuts-and more radical sorting-out and reform of the public sector. I return to my main point: you will not get the economy going if you go round putting up taxes too much.
However, the trends do not look too bad. Corporate profitability was up 37 per cent last year-admittedly, on a terrible previous year-and it was remarkable that 420 jobs were created in the private sector in a year that none of us thought was particularly encouraging.
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I want particularly to rebut what I am afraid I view as rather Luddite and misguided economic attacks on the financial services sector. The main criticism is of two individuals whose reckless behaviour led two major banks into bankruptcy and to a failure of monetary policy-for which the Bank of England was responsible -and of regulatory policy. But banks are not the whole financial services sector by miles. It is surely appropriate that a mature economy such as the UK should have a large amount of activity in that sector-I might add that it is a great deal larger in Hong Kong. The biggest bank in the world, HSBC, came through it all without any trouble and any need for public sector or taxpayer support.
Let us remember that that industry generates some £100 billion of exports, some 1 million jobs and £55-odd million of tax revenues, and that London contributes something like £50 billion a year to the rest of the economy. London has been the great success of this country.
Lord Lea of Crondall: My Lords, I shall not surprise the House by saying that the analysis of the noble Lord, Lord Flight, is totally the opposite of mine. His is the ideological analysis that lies behind the present Government, a Government who are driving the economy to the wall. Perhaps he and I could have a bet on it.
The noble Lord compared us to Hong Kong. Hong Kong's logic is effectively to be understood as part of China. It is an enterprise zone for the Chinese economy to some extent and it has a degree of inequality that even the noble Lord, Lord Flight, I assume, would not advocate for this country. The model set by our country with its history, as a northern European country playing a successful part, along with Germany, Holland, Sweden and others, in European society, is not one I hear spoken of as part of the ideology coming from the other side. In fact, the noble Lord's speech could be summed up as: private sector productive; public sector unproductive. Are people in education not productive? Are people in health not productive? These are caricatures.
I recognise that a question has to be put to the Labour Party and people such as me: what is the alternative? To the wonderful march on Saturday, in which 500,000 people took part, the Government's response was that we did not put forward an alternative. I do not think that putting a sticking plaster on the present arrangements is the solution, whether it be the operation of the auditors-a mutual admiration society as analysed in our own Economic Affairs Select Committee report published yesterday-or typical boards of directors or the merchant banks. As was pointed out by my noble friend Lord Eatwell the other day, boards of directors in this country do not represent anybody apart from themselves. The churning of shares
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In the middle of all this, what is it that Britain is lacking in the four cylinders of its motor car engine firing at the moment? Let us look at the way in which the German economy operates, with its supervisory boards-which I advocate for this country. Let us take a fundamental look at the Victorian company law which we operate even now, more than 150 years since it was written; it is essentially the same. I offer an anecdote. A CEO of a company in this country went to Sweden and the first question put to him was: "How is this takeover, if it goes through, going to help our world market share?" That is not the experience of board members in this country. They are part of a cabal, answerable only to themselves.
Lord Mawson: My Lords, the sector that is always neglected when politicians and civil servants look at growth strategies is the faith community. On 22 February last year, I led a debate in your Lordships' House that explored the future use of nearly 50,000 church buildings standing in the middle of virtually every community in the United Kingdom. Building on this debate, on 25 March last week I hosted a national conference at Gorton Monastery in Manchester where the noble Lord, Lord Wei, spoke about the big society. Here, I must declare an interest as a director of the social enterprise, One Church, 100 Uses, which organised the event.
There are many church assets and resources in communities across this country that do not receive the recognition they deserve. At Trinity United Reformed Church in Gosforth, Newcastle, the congregation is leading a business improvement district bid built on the back of the work that has been done during the past decade reconfiguring three church buildings and establishing an enterprise hub which is now redefining the centre of the town. Today, this church is a major local employer.
Gorton Monastery, the conference venue, is today run as an enterprise specialising in banqueting, conferences, weddings and business bookings. Yet a decade ago, this was a cathedral-like building that stood derelict and desecrated. Following a £6.5 million restoration scheme, led by the social entrepreneur Elaine Griffiths and her team, the Monastery Trust, this formerly unused asset now sits alongside the Taj Mahal and the ancient ruins of Pompeii in having being listed among the 100 most endangered heritage sites in the world.
Another national example is the Bromley by Bow Centre in east London, which I founded-I must therefore declare an interest. It grew out of a local church congregation of 12 elderly people. It now has 31 established businesses and has an active business
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However, while I am delighted that many churches are embracing the idea of the big society, there are significant problems that will hinder their existence. We all know that the macro growth of the British economy depends on the success of thousands of small businesses like those I mentioned. These entrepreneurial cultures take time to build. To undermine them when they are starting to fly is not wise in the long term. The present financial cuts, made irrespective of local context, are threatening the additional unpublicised services that are deeply embedded in thriving entrepreneurial centres.
In East London, at the Bromley by Bow Centre, the CEO, a businessman by background with considerable financial skill, is struggling to shave more than £1 million from his budget because of the scale of the cuts that the organisation faces. He is losing vital services. Despite the rhetoric from the Government, social enterprises are often being disproportionately disadvantaged by the cuts when resources are allocated from central pots and from local authorities.
I suggest that the big society depends on micro businesses as exemplars to lead the way.I therefore request that the Minister actively explores practical ways to identify, promote and foster economic growth within this emerging entrepreneurial sector across the UK. Much of it is based in some of our most challenging communities. The social sector is formed from many shoots and distinctions need to be drawn to protect these young entrepreneurial flowers. Will the Minister please inform the House how the Government plan to empower social enterprises in some of our most challenged communities?
Lord Davies of Oldham: My Lords, it is a delight to follow that constructive contribution from the noble Lord, Lord Mawson. It was partially trailed by my noble friend Lord Layard, who indicated this aspect of social capital is something to which the Government should pay attention with the concept of the big society. I hope that the Minister will address himself to that point. Of course, these contributions are a reflection of the fact that we all owe an enormous debt to my noble friend Lord Hollick for choosing this as a subject for debate today. It has given the House an opportunity to be constructive and thoughtful about positions for the future in circumstances where we all appreciate that the country faces tough times ahead. It is important that we are able to chart the routes to the future which promote the well-being of our society. Typically, my noble friend Lord Hollick indicated in his speech potential areas of entrepreneurial growth to which I hope the Minister will respond.
Also in the debate, we had five maiden speeches in which all noble Lords rose to a significant challenge today. They had to express, as we all feel, the privilege
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As my noble friend Lord Haskel indicated, this is the third economic debate we have had on successive Thursdays. In past weeks, we have somewhat aired our differences of perspective on economic policy. An element of that inevitably underpinned this debate. It was brought to the fore by the noble Lord, Lord Skidelsky, and supported by my noble friend Lord McFall who indicated another perspective that is different from the Government's-a perspective showing that the Government are taking great risks with the economy and the welfare of our society. Her Majesty's Opposition have been articulate in identifying an alternative route, of which the outstanding feature is that the Government are bent on reducing the deficit within the minimum period of time-a single Parliament. In doing so, they are asking the country to be subjected to cuts that will affect the well-being of large sections of the community. But those cuts also affect the growth potential of the economy.
In this debate, noble Lords have identified where these cuts may do harm to the important, long-term economic development aspects of public investment. I know that the Government stress only the private at the present time. None of us doubts the importance of the private sector in terms of growth, but one cannot set at nought the public sector. Nor can one cut it without engaging on a strategy of some risk.
As a number of noble Lords identified, our education sector will be under great pressure. Our universities will be significantly starved of public resources and will have to depend on the free market in terms of the response of students. We do not know whether that will lead to a reduction in resources for the universities because students are unable or unwilling to pay, and we do not know the impact on recruitment. However, we do know that when these reductions take place the impact on research in our country, and on the development of a great deal of the fundamental basis on which creative activities can take place in the economy, may be seriously hurt.
In particular, it seems that we are the only country engaged on cutting the science budget, while all other countries regard it as an essential investment. We have a significant contribution to make in science and have a prime position in terms of our world role. However, we must be careful about the danger of losing that position as a result of the Government's strategy.
It was indicated in the debate that we should not underestimate the creative sector, which is an important growth area of our economy. It was referred to by my noble friend Lord Kestenbaum. Creative activity and the genius of British people, which is translated into effective and constructive activity in the media and the
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As my noble friend Lord Layard emphasised, whatever the difficulties with regard to higher education, we should be extremely concerned that this continues to be a society that undertrains and undereducates a substantial section of the population. That is why the Government's contribution with regard to the modest number of places in apprenticeships and training schemes is a minute dimension of the need that is required to ensure that we have a population sufficiently skilled to make a contribution to our society and earn their living in this world. Cutbacks in that sector-and colleges are suffering very substantial cutbacks-and the loss of the guarantee to which my noble friend Lord Layard made reference is a very serious blow.
Another dimension of this, our transport infrastructure, was introduced by my noble friend Lord Soley and the noble Lord, Lord Birt. I give due credit to the Government with regard to rail investment and the fact that crucial areas of it are being sustained. But my noble friend Lord Soley is absolutely right when he says that there does not appear to be a concept of an aviation policy when aviation is bound to play a very significant role in the economy. The noble Lord, Lord Birt, also, identified our difficulties with regard to road.
Another dimension on which I give the Government credit is the Green Deal. They are continuing policies which the previous Government adumbrated, but we are looking forward to the whole development of house insulation and improvement with regard to conservation of energy in the home. The Government deserve credit for their commitment in that area. But as my noble friend Lady Worthington indicated, it is not so certain that the commitment to the green bank and the whole environment development is so secure.
There are tough times ahead. We all recognise that the nation has got to identify areas of potential growth. But I emphasise this one other dimension, which my noble friend Lord Wood introduced into his all-too-brief speech, when he reflected on the concept of fairness. If we are all in this together, there must be some concept of fairness across society. It will not do that the Government rely upon the failed Project Merlin for their temporising with regard to the banks and their pathetic gestures towards seeing the banks make some reparation and take some responsibility for the disasters of the past, while pursuing policies with regard to social cutbacks which hit so adversely the least well-off in our society.
I am grateful that today we have moved from a position of significant division to one in which there have been some very constructive proposals on growth. I hope the Minister will be able to give us encouragement that he intends to pursue the majority of them.
The Commercial Secretary to the Treasury (Lord Sassoon): My Lords, we have had a tremendously interesting and wide-ranging debate today. I thank all noble Lords who have contributed, particularly the
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I completely agree with the noble Lord, Lord Davies of Oldham. It has been an overwhelmingly constructive debate, in which many positive ideas have come from all round the House, and this presents me with an additional challenge today. Last week I attempted, maybe foolhardily, to make some mention of all noble Lords' contributions to that debate. But I know my limitations. Today, with even more speakers and an even shorter time to respond, I apologise in advance but I am not going to be able to make mention of everyone who spoke. There were lots of good ideas, not all of them workable, but it is right that you should push the envelope in imaginative ways, whether in the use of faith buildings or encouraging science in schools. There are all sorts of great ideas coming from around the House, and I will make sure that those are considered by the Treasury or the other departments responsible.
In general, the message I take away is very welcome, because I know that the temptation is for us all, or for a lot of us, to be making political points. The message that I take away is that there are many good things in the Budget and in the growth document that went with it, but that we have to work harder-I understand that-and consider lots more of the ideas that are coming up. In the phrase of the noble Lord, Lord Hollick, it is a worthy and promising start. I appreciate that. I take to heart the big challenges for us-that we must be bold and not timid as a Government. I agree, and I will come back to that. We must always remember the big picture. I agree with that. We have to live up to the challenge of the Government's part of the bargain of delivering and not just making promises. I will come back to each of those themes in a minute.
I start by acknowledging the five excellent maiden speeches that we have heard today-from the noble Lords, Lord Kestenbaum, Lord Wood of Anfield and Lord Collins of Highbury, my noble friend Lord Popat, and of course the noble Baroness, Lady Worthington, who has confused me by moving seat. I am glad to see that she is back in the Chamber. There was a common and very important theme in those speeches, some of it put very movingly, about what this country and this House have done to foster diversity, whether of ethnicity, faith, gender or sexual orientation. Of course, we must not forget that diversity in hair colour is also a feature of life. The maiden speakers also, by their diverse backgrounds in business, academia, the unions and the environment, and by the quality of the individual speeches, could make no better case for this making a genuinely value-adding House that we are all part of. That was a great addition to what was, in any case, a very important debate.
I remind noble Lords of the context of this year's Budget and growth plan. The Budget is about reforming the nation's economy so that we have sustainable growth and jobs in the future. "Sustainable" is a word
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Last week's Budget was built on clear economic principles of sound public finances-and no wavering on that-but support for private sector growth, reward for work, help with the pressure of high fuel prices in the short term and a new vision for growth. That vision for growth has four key ambitions at its heart: that Britain should have the most competitive tax system in the G20; that Britain should be the best place in Europe to start, finance and grow a business; that Britain should be a more balanced economy by encouraging exports and investment; and that Britain should have a more educated workforce that is the most flexible in Europe. Those noble Lords who had the stamina to be here during last week's debate as well will know that I went through each of these four areas thematically. But let me today take a slightly different cut through the issues, prompted very much by the challenge of the noble Lord, Lord Hollick, that we must be bold and that timidity is not enough. That is linked to the challenge from a number of noble Lords that we must attend to the big picture.
Let me suggest to your Lordships a number of areas in which I believe we are being bold and addressing the big-picture issues. Take corporation tax: the fact that we are heading, in three years from now, down to a corporation tax headline rate of 23 per cent, which will take us to the lowest rate in the G7 and one of the lowest in the G20. I suggest that that sends the clearest signal possible around the world that this country is again open and welcoming to all businesses to come and base significant global operations here.
Deregulation is a difficult, challenging topic which the previous Government worked hard on but we have to find new ways of tackling it credibly. Again, we will be bold so we are starting right now with a new initiative to put tens of thousands of individual regulations on to a public website. Two weeks at a time, chunks of regulation related to a specific part of the economy will be open to challenge. At the end of the period of public challenge, it will be up to the departments concerned to argue why any regulations which have been challenged by the public must stay in place. The presumption of the committee led by my right honourable friend the Business Secretary will be that if people identify a regulation that has to go, it has to go unless there is an overriding reason for it to stay. I suggest that is bold.
Planning is a critical issue for growth in this country, and we will bring out some draft new planning guidelines within the next few months. They will have in them a fundamental new approach which has, at its heart, a presumption in favour of sustainable development. In addition, the new planning rules must have a process in place where the entirety of planning, including
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A number of speakers brought up the field of energy and the question of setting a carbon floor price was raised. I suggest that setting a carbon floor price is a bold, difficult but necessary part of underpinning the huge amount of new energy investment which this country needs, so we will not shy away from taking the difficult decisions.
Lord Davies of Stamford: Will the Minister not acknowledge that although setting a carbon price might be very desirable if it was based on international agreement, if it is based on a purely unilateral or national move we shall be handicapping our industry and our growth, and contributing nothing at all to the reduction of global warming?
Lord Sassoon: My Lords, I do not wish to be discourteous to the noble Lord, Lord Davies of Stamford, but if I am to do justice to at least some of the points that have been raised in the debate so far, he will perhaps forgive me if I do not answer his question in intervention. I would rather do justice to some of the points made in the debate.
On education and bringing people into the workforce, I could mention a number of initiatives but let me just draw attention to the apprenticeships. Those are one key plank of what has to be a bold transformation of young people's appreciation of the different and valuable routes into work. The total number of apprenticeships that will be available over the next four years is 1.1 million, so the Government are playing their part in making the apprenticeships available. I hope that, as my noble friend Lord Newby has said, business will rise to the challenge of taking up those places. Again, these are big-picture issues and this is, I suggest, a bold approach.
Lastly, there has been mention from a number of angles of the challenge to get finance into our corporate sector, whether SMEs or the whole of industry. We have set the banks the challenge now, through the deal that we have done with them, whereby they have agreed to make up to £190 billion of credit available for new loans, and more if it is necessary. That very significant amount of money should meet the reasonable demands of growing businesses in this country. When the banks are under considerable pressure to manage their balance sheets more prudently under new capital and liquidity rules, I suggest again that getting financing through to businesses is one of the big-picture challenges and that we as a Government are rising to that challenge in a suitably bold way.
Another big-picture theme that has come up a number of times and which deserves particular recognition is that of infrastructure because, again, the size of the challenge is enormous. A number of speakers raised this, the noble Lord, Lord Hollick, first, with the noble Lord, Lord Bilimoria, and others following after. We have identified £200 billion of infrastructure investment as being required over the next five years in economic infrastructure alone: in energy, water,
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We committed in the growth programme and the Budget to coming up with a rolling forward programme of infrastructure projects, so that we can start to give much greater certainty than there has been to the construction and financing industry in this country. If we expect businesses and financiers to take the strain, which they will do on 60 to 70 per cent of that £200 billion of infrastructure, we need to give them some clarity about where these programmes will be directed, so that is what we will do.
In answer to the specific challenge from the noble Lord, Lord Soley-although he knows this well-it is worth restating that, yes, aviation policy is very important. That is why my right honourable friend the Transport Secretary took time to work up a consultation paper that was published yesterday. I acknowledge that it may not meet the aspirations of all interests in the aviation sector but it is the start of a critical debate. I acknowledge that that debate must be had: that is why the consultation paper has gone out on aviation policy, which is one critical component. Alongside that, I acknowledge the references that were made to our commitment as a Government to high-speed rail. We must look at transport within a holistic and complete picture.
In this general area, there were also a number of references to the desirability of a green investment bank, a national investment bank or an infrastructure bank; your Lordships expressed it in a number of ways. I entirely understand the ambitions of the noble Lord, Lord Skidelsky-the noble Lord, Lord McFall of Alcluith, made this point as well-but without going into the technical details of PSBRs and how government accounting works, the first thing to say is that having a very large national investment or infrastructure bank is simply not possible given the constraints that we have on the Government's balance sheet. However one looks at it, this would score against the national borrowing. Even if the case were made, and there are strong proponents on both sides of the argument about how big a green or a national investment bank is required, we have to be realistic about the constraints of the public balance sheet.
Within that, we announced last week in the Budget that we have brought forward by one year the starting date for the operation of the green investment bank to 2012-13. I do not want to make political points, but this Government for the first time have committed the money-£3 billion. That is a good start. We have committed money to this project in a way that there was previously a lot of talk about over the past few years. The bank will be able to leverage in private sector money so, even though in the first couple of years of its operation it will not be able to have its own borrowing, the leveraging effect of the green investment bank, by working with private sector investors, will be
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That is to address a few of the specific points made. I end by drawing attention to one or two of the reasons to be positive, which are very welcome. Yes, there are huge challenges, but the noble Lord, Lord Rees of Ludlow, reminded us about the latest Nobel prize-winning team, working with graphene, that has been based in this country and the need to exploit that; the noble Lord, Lord Mitchell, talked about Silicon Roundabout with great passion and the way that that will translate through the Olympic legacy and Tech City into something that is really lasting; my noble friend Lord Flight talked about the 428,000 jobs that were created in the private sector last year; the noble Lord, Lord Bhattacharyya, talked about our great strengths growing again in manufacturing and exports; and my noble friend Lady Wheatcroft gave us a specific example in the design and textile world of what we can do.
This has been a wide-ranging debate. I take from it a great challenge to Government, which I assure noble Lords the Government are committed to driving through. I also take away some great strengths that we have to work on. The Government are putting our economy back on the right path. We are supporting and will support enterprise, and we are driving innovation. We are doing our part as a Government to invest in skills, jobs and infrastructure. The Budget stands firm on our plan for the recovery; it is a plan that is good for business and good for growth and will help to create the prosperous economy that the people of Britain deserve.
Lord Hollick: My Lords, this has been an excellent debate. I thank every speaker for the informed and constructive way in which it was conducted. There were many excellent ideas and there have been five outstanding maiden speeches, which give us a glimpse of the formidable contribution that our new colleagues are going to bring to our debates.
The Minister has not had the opportunity or the time to go through each and every one of the suggestions that was made. Perhaps he will find an opportunity in future to do that, and perhaps he will take up the suggestion of the noble Lord, Lord Higgins, of having a meeting in the Moses Room to discuss some of these things. The contribution that has been made today is worthy of continuing discussion and serious consideration by the Government. With that, I beg leave to withdraw the Motion.
Lord Turnberg: My Lords, I am delighted to have this opportunity of opening this debate. I am pleased that so many noble Lords are remaining in the Chamber and are going to contribute. I look forward to hearing what they have to say.
I shall focus my remarks on recent reports of failures in standards of care, particularly for the elderly, but this is also a good opportunity to examine whether the commissioning arrangements proposed in the new Bill will have a positive or a negative effect on standards of care. Perhaps, too, we should look at how the Bill might be used to make things better.
I am someone who has spent most of his life working in the NHS and I bow to no one in my support and admiration of what it achieves. I see enormous advances being made every year, and patients who would no doubt have died are now cured and surviving into old age. Medicine has been transformed out of all recognition during my working life.
It is because I have this pride and huge admiration of the NHS and the people who work in it that I now feel a deep sense of shame. Despite these wonderful advances, in too many places we have been ignoring the common decency needed to care for the vulnerable, the sick and the elderly-and it is the elderly who are often the most vulnerable. As Ann Abraham, the Health Service Ombudsman, said in her report, there is a,
That is why I am going to focus on the elderly, but they are not the only group where standards have slipped. I suspect that other noble Lords may speak about the mentally ill, and only the other day we had a report about failures in maternity services.
Of course, the media are quick to pick up the seemingly occasional horror stories of neglect in a hospital. You might want to hide behind the idea that these are rare incidents against a background in which 1 million people are looked after perfectly well in our hospitals and nursing homes every 36 hours, and that is absolutely true. But it turns out that it is not a rare or unusual event. It seems to be happening far too often, and stories of neglect are just too common for comfort: patients, usually in a geriatric ward, unable to eat the food left out of reach at the end of the bed and collected by staff seemingly unaware that it has not been touched, and too busy to notice that a thirsty patient is unable to even drink without help-or, worse, too busy to notice that a helpless patient, unable to get out of bed and incontinent, is sitting in damp sheets for hours or, the final degradation, soiled by faeces and unwashed for days.
Noble Lords might ask whether I exaggerate. Where is the evidence that this picture is not just a rare, occasional lapse in an otherwise acceptable system of care? Well, quite apart from the rather common anecdotes of many with elderly relatives, there is now the report of the ombudsman in which she describes 10 examples of the complaints she receives that emphasise just how bad it can get.
We cannot say that we have not been warned. In 1997 we had the report from Age Concern in its "Dignity on the Ward" campaign, describing failing
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The scandal at the Mid Staffordshire hospital of a year or so ago turns out not to be an isolated example. Every time we have a disastrous fall in standards we have another report or inquiry. I will not list all the hospitals or nursing homes that have been the subject of criticism but they range from Cornwall to Rotherham, from Tameside to Southampton and from Oxford to Bolton. There are just too many, and it is clearly not a new phenomenon. It went on under the past Government and the one before that, so I do not want to make any political points here. But how can we have tolerated this neglect of our most vulnerable citizens for so long? No one can afford to be sanguine-not the doctors, not the nurses, not the managers and not the Government. I want to say a few words about why and how this is happening and suggest what we might do about it, because we certainly cannot allow it to go on.
Let me apologise for starting with the nurses, for whom I have the greatest admiration and to whom I owe a great deal of personal gratitude. However, at the end of the day, it is the nurses who patients look to first for their personal care and empathy. It is always tempting to look back to a golden age that never was, but one thing that is clearly fixed in my mind is how high the standards of nursing care were on the medical wards where I worked in the 1950s and 1960s. Those were the days when the sister in charge of her ward really was in charge. She was usually a mature woman in a career job who made absolutely certain that everything ran efficiently and well. I admit to running scared of her; as, indeed, did the patients.
However, those were the days before the revolutions in nurse management and nursing education. One of the unintended consequences of the upward drive to better educated nurses with university degrees has been the development of a generation whose aspirations are set high. They quite reasonably expect to have a career in which they can practise their skills to a high standard. Who can blame them? They do a great job with all the caring attitudes you can wish for. However, that has left a gap at the more basic and, to many, less attractive level of the general and geriatric ward where there is greater emphasis on the basic needs of patients: feeding, washing, help with movement, going to the toilet and so on.
Those are the wards where staffing levels are often lower per patient in the belief that they do not need the more intensive, one-to-one care of the specialist units. So they are often understaffed and sometimes come to rely on temporary, or "bank", staff, who constantly change. Continuity of care is damaged as patients, already a little disorientated by being removed from their familiar environment, are faced with a bewildering series of new faces.
It is not only the nurses who are constantly changing. Confusion is compounded by the way the rotas for the ward doctors are arranged to fit in with the European working time directive or as they rotate through yet another experience to chalk up on their training programme. So there are new faces at every turn. These wards do not have the champions that the specialised departments have, who can put pressure on management to protect them from cuts. Not much wonder that nurses in training pass through those experiences quickly on their way to higher things. Nursing sisters in charge may not stay long enough to be able to stamp their authority and, in any case, are distracted by paperwork or, nowadays, putting stuff into their computers-care plans and the like.
I fear that these changes have created a situation in which we have two starkly different standards of care. On the one hand we have highly trained, highly professional and caring nurses in well staffed specialised units-intensive care, coronary care, chemotherapy units and the like-and, on the other hand, poorly staffed wards, rushed nurses, falling morale, falling standards and poor supervision. These are the staff who are struggling to cope with patients whose vulnerability makes enormous demands for the care and attention that the nurses have neither the time nor the patience for.
So what is to be done? Here it is clear that there is a need for a multifocused set of actions which no one profession or body can shirk. First, we must have someone at ward level who takes full responsibility for ensuring that patients are properly looked after with the respect and dignity that they deserve. That is absolutely key. I hope that my nursing friends will forgive me for saying that we should be making this job, the ward sister or charge nurse, a career post and rewarding those who do it accordingly.
Then there is the issue of too few carers on the wards. What happened to all those state-enrolled nurses-SENs-whose roles were predominantly in the caring world and who did not aspire to higher degrees? They disappeared in project 2000. Is it possible for us to resurrect the SEN grade and make it attractive again? I hope that some thought can be given to that.
That leads me to the medical profession, who cannot absolve themselves-ourselves-from responsibility for the neglect we are now discussing. They, after all, must see the way their patients are being cared for and, I am afraid, have not raised their voices loud enough. They should be leading the charge for proper staffing levels on their wards. They should be pressing hard on the managers of their hospitals. Of course, they really must do something about these disruptive rotas that are destroying the continuity of care that patients need and deserve.
The managers must make themselves much more aware of their responsibility to ensure that there are sufficient staff on these wards to cope with what is one of the most demanding areas of a hospital. They should know that these wards cannot be among the first, for example, to take cuts. Then there are the responsibilities of the trust boards. Board members have to be rather more hands-on and need to know what is going on in their wards. Many obviously do, but it seems that there are too many who do not.
Finally, I come to those bodies who will be commissioning services in the bright new tomorrow, the GP consortia, and the responsibilities that we should be placing on them for standards of care in the NHS, under the Health and Social Care Bill coming through the House-in whatever form that Bill survives. To paraphrase Aneurin Bevan, there are bed pans clanging on the floor all over the country and, in the rush to devolution to the local level, important though that is, devolved responsibility must also mean some central accountability.
As these services are commissioned, we must make sure that the Bill places a duty on the GP consortia to make sure that high standards of care for the elderly, at least, are a contractual obligation on the providers. Furthermore, we must have a robust system of monitoring so that we can have some confidence that this care is actually being provided. Perhaps the proposed commissioning board can take this on, but only if it has the capacity to monitor what is going on in hospitals and nursing homes, and has a mechanism for action when standards slip.
The Health and Social Care Bill represents a once in a lifetime opportunity. However, we must not forget that it is built on, and expands in much greater depth, the fundholder initiatives that existed in the National Health Service between 1991 and 1997, when they were stopped in their tracks by the then Secretary of State. I assure the noble Lord, Lord Turnberg, that that is the last political point I shall make. There were, however, some welcome initiatives introduced by the previous Government, of which two were the creation of foundation hospitals and the introduction of practice-based commissioning groups.
The current reforms under the leadership of my right honourable friend Andrew Lansley seek to build on the reforms of the 1990s and the more recent ones of the previous Government and to capture the advantages and discard the disadvantages of both. At the heart of the Health and Social Care Bill lies the increased emphasis on bringing the patient into the decision-making process, and many of the reforms flow from that. Like, I am sure, many speakers today, certainly the lay speakers, I have canvassed the views of a number of
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Among the general practitioners there is the age-old agony for the conscientious GP as to how much time he or she will be required to give up for the management of the consortium, at the expense of treating patients. The evidence from the early experiences of the pathfinder consortia shows that many able practitioners have come to terms with this issue and are able to adjust their professional lives around it-and the consortia are at the heart of these reforms. They will take the place of the primary care trusts. What, then, is the difference? The main difference, as I see it, is that the PCTs have seriously little clinical input. This, by contrast, will, I hope, be the strength of the consortia, which will be clinically led. These consortia, to which every general practice will have to belong, will have the resources to back up their constituent practices and will commission secondary care.
The document Liberatingthe NHS: Legislative Frameworkand Next Steps is, I suggest, a model of its kind. It is readable, positive and forward-looking. I wish to speak about one of the specific matters mentioned in it-the provision of specialist services. It is known that some disabled charities are concerned that some specialist low-volume and often expensive services which they use will be lost. The paper specifically provides for this by encouraging consortia to work together to share such services, and for these to be commissioned by the NHS Commissioning Board. This is but one example of the many relatively minor issues which have been addressed in the paper and demonstrates the flexibility of the proposed consortia structure.
Much has been made of pathways in the paper, and these are at the heart of the proposals in the relationship, initially, between the patient and his or her GP. If the patient cannot be treated within the practice, the GP will negotiate with medical colleagues in the consortium, who will in turn negotiate with the provider. Note the clinical input at every stage.
Time does not permit me to make anything but passing reference to the very welcome initiative proposed to combine many of the functions of healthcare and social services under the health and well-being boards. The point that the noble Lord, Lord Turnberg, made about the care of the elderly is crucial to this combination. This is a very important and long overdue development.
I asked a GP who had given me considerable help in preparing for this debate whether there was any point that he would like me to make. He said without hesitation, "The NHS has for far too long tolerated poor performance by general practitioners". I suggest that this is at the heart of these reforms.
Lord Alderdice: My Lords, we are all indebted to the noble Lord, Lord Turnberg, for obtaining this debate. The only unfortunate thing is that he did not
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As the noble Lord pointed out, over a considerable time there has been a deterioration in what I might describe as the culture of care. I say "care" rather than "treatment" because, as he rightly pointed out, specialist, high-quality, acute treatment is often of a very high standard indeed; but in areas such as the one closest to my heart-care of the mentally ill, whether in the community or in in-patient care of various kinds-or care of the elderly, as he rightly pointed out, that long-term care has often deteriorated because of cultural changes in the NHS itself. I shall explain what I mean by that.
As the service expanded and became more complex, there was an increasing and necessary focus on management. It became increasingly the case that those who progressed would move into management. The noble Lord referred to this. In most professions, such as social work, psychology and particularly nursing, if someone wanted to make progress, inevitably they moved out of direct clinical care. For the ambitious and capable young nurse, for example-although this state of affairs was not confined to nursing-to make progress in the profession meant focusing on training and development, to move out of direct clinical care and into management, rather than making clinical care a long-term career commitment.
For obvious reasons, this disadvantaged the concern and commitment of the ambitious and capable young nurse for clinical care; the culture was to move into management. Doctors moved in the other direction. They continued to focus on clinical care-even when they got into management, they rarely gave up care completely-but that meant that they were disadvantaged when they were good managers. They tended to let go not of the care side but of the management side, which increasingly became detached from medicine, so doctors became disenchanted with the whole process of management.
In their different ways, our different professions found that the domination of management in the service took us away to a management culture rather than to a professional culture of devotion and care, which is what our NHS ought to be about. It is that change that we need to find a way to reverse. This is the idea of the reforms that are proposed. They are not necessarily the same as the proposals that will come forward, and it will be your Lordships' responsibility to try to change things in such a way that the principles are best expounded in the legislation and ultimately in its implementation. The challenge is how we move to less management focus in care and to more clinical focus, and focus on the patient.
We must move to greater local accountability; greater clarity of governance; competition in quality of care and not in the price of care, because that will be set down in tariffs; and to ensuring that there is a greater
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Baroness Emerton: I thank the noble Lord, Lord Turnberg, for raising this timely debate. Without doubt, corrective action is required to deal with these issues. They will not go away unless that happens. This fact is reflected in the 57 per cent increase on last year in referrals from the general public to the Nursing and Midwifery Council fitness to practice committee in the months of January and February this year. The total was 833-a dramatic increase.
On 3 March, I asked when the Government were going to respond to the report of the Prime Minister's commission on nursing and midwifery, published in March 2010. I declare an interest: I am proud to say that I am a nurse and that I was on the commission. The Minister replied that he would check where the Government were on the formal reply. I raise this again as no response has been received and because a year was spent by 20 senior and distinguished nurses, midwives and health visitors looking at the problems that faced us.
Evidence was collected following meetings with the public, stakeholders and students, and left the commissioners in no doubt that a "care quake" was approaching-driven by healthcare trends, social changes, demographic changes, families outsourcing care, growing numbers of people with long-term conditions and the additional complex conditions resulting from the ageing process. The nursing professions are centre-stage to handle the care quake, but must be properly equipped and supplied to deliver truly compassionate care that is skilled, competent, values-based and that respects patients' dignity with clear, respectful communication to patients and relatives.
We gathered from extensive engagements with the public that they felt strongly that the public image of the nursing, midwifery and health-visiting professions is out of date and that a new story of nursing is needed. The clearest message was that the traditional image of the front-line sister or leader of a community nursing service should be restored to the former point of visible authority and clear leadership role, answering the cry, "Who is in charge?", at front-line level.
The commissioners set to work to make recommendations for the largest single workforce in Europe. There are currently in excess of 625,000 nurses on the register. The NHS nursing and midwifery pay bill is £12 billion, with more than £l billion spent on pre-registration nursing and midwifery education. There is little research on the cost-effectiveness and cost-benefit of nursing-led services, and existing research is often ignored. A recent scoping review commissioned by the Nursing and Midwifery Council found that there were 300,000 healthcare support workers in the NHS that
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The move to make nursing a degree-level profession by 2013 is an integral step in ensuring that registered nurses and midwives have an academic base to translate into high-level, quality compassionate care.
Of the nursing commission's 20 recommendations, I wish briefly to highlight four. The commission said that the nursing, midwifery and health-visiting professions should deliver high-quality care and that leaders should accept full managerial and professional accountability for ensuring that the organisation provides high-quality, compassionate care. The boards should ensure that care champions strengthen the front-line managers-for example, sisters and charge nurses. There was a call for advanced practitioners and healthcare support workers to be regulated, protecting the title "nurse" and limiting its use to those on the NMC register. This would be equivalent to "enrolled nurse", as has already been mentioned. Another recommendation was that nurses and midwives should contribute to health and well-being, reducing health inequalities.
I hope that Her Majesty's Government will respond quickly and positively to the commission's recommendations, which all go towards achieving an improved nursing profession that will meet the needs of the community with compassion and with respect for the elderly.
Baroness Northover: My Lords, perhaps I may remind noble Lords, as I did in the previous debate, that we have a very tight time limit in this debate. Therefore, when the Clock reaches "4", noble Lords will have completed their allotted four minutes.
Baroness Sherlock: My Lords, I thank my noble friend Lord Turnberg for securing this debate and I declare a non-pecuniary interest as the next chair of Chapel St, a charitable enterprise which delivers services in partnership with primary healthcare.
I should like to wave another report at the House. This one came out last week. It is from the King's Fund and is called Improving the Quality of Care in General Practice. In fact, it begins where the noble Viscount, Lord Bridgeman, left off, looking at variations in care. The report was the result of a major inquiry conducted over two years by an independent panel. The panel looked at general practice and found that most care is good, which is a relief, but it also found that there is a widespread variation in performance, as well as gaps in the quality of care delivered by general practice. The report is full of examples, which I commend to the House. It showed variations in the quality of prescribing, in the quality of diagnosis-for example, one-third of patients with stomach or oesophageal cancer who required urgent referral to hospital were given non-urgent referrals-and in the rate of referrals.
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Almost as telling was the fact that it found a significant problem in accessing public information, particularly comparative data, on performance in general practice. When we consider the avalanche of data available for almost every other part of the health service, that is quite striking, and I should be interested in hearing the Government's reaction.
I see that the noble Earl, Lord Howe, told the Health Service Journal last week that, in response to the report, the Government's plans to move 80 per cent of the NHS commissioning budget to GP-led consortia will improve this situation. I am very keen to learn how, and perhaps the Minister will take the opportunity to explain it to the House. He may not want to go into detail today but I wonder whether I can encourage him to assure the House that he will engage with the King's Fund, as well as with the Royal College of General Practitioners and the BMA. I was delighted to hear that they both welcome the report, so there is a fair wind behind it, but perhaps the Minister will engage with them in looking at how these problems can be tackled. Perhaps, in particular, I could encourage him to do so before this House starts to look in detail at the Health and Social Care Bill that will be coming before us.
For me, this report could be a metaphor for the state of the health service: most general practice is good; the NHS is good; popular satisfaction has never been higher; its efficiency is admired; but there are pockets of significant problems, as described by my noble friend Lord Turnberg. It is clear that performance and outcomes vary too much. We all want to see continuous improvement and we all are open to the idea of changing how healthcare is delivered. However, it is not at all obvious to me how the revolution in the health service, on which the Government are embarking, will necessarily solve these problems. Risks will inevitably be taken by such large-scale reform, so not just this House but the country needs to be persuaded that the changes will produce results that will solve the kind of problems that have been identified. I strongly encourage the Minister to look not just at the specific problems raised but to say why the Government think that their prescription will cure the ills. That is the challenge for all of us.
When I thought about what I would talk about today in my four marvellous minutes, I went back to a list of notes that I had made at the wonderful all-party seminars that many of us have attended with experts in the field, and I found a list of 20 questions to which I did not know the answer. It is not simply a list of questions that I cannot answer, as that would be a rather greater list, but a list of questions to which the experts at these seminars had been unable to find the answers after carefully reading the Bill and all the associated documentation. If that is the case, we have to question the wisdom of proceeding at the current pace. This House has enormous respect for the integrity and experience of the Minister. I wonder whether he could speak to his colleague the Secretary of State and
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Baroness Hollins: My Lords, I, too, am somewhat daunted about speaking about my interests in this debate in such a short time, but I am grateful for the opportunity. I note that the Care Quality Commission has just published its second annual report. Encouragingly, it talked about safer services and an upward trend in the standards of healthcare.
Noble Lords would expect me, as a former president of the Royal College of Psychiatrists, to speak about people with mental illness and learning disabilities. I shall do that but I will focus on the physical health of people in that group and their access to acute hospital services. That relates to commissioning. Although I do not think that commissioning is the key to all the problems in the NHS, strong commissioning is important. At the moment, commissioning largely does not understand the needs of people with learning disabilities and mental illness, particularly when their needs are complex and they are seeking care in an acute hospital setting. I shall try to explain what I mean and will give two examples.
If we stop to think about maternity services-my noble friend Lord Patel may have a different view-we find that the most complex kind of maternity case is a mother with a severe mental illness. However, the current tariff does not cover the mental illness that that mother has and the obstetric department does not have to purchase mental health services to look after that mother. That is a real shame, as this is a good moment in a woman's life to attend to her mental health needs and the mental health needs of her child. That is just one example.
The Bill sets out clearly the kind of duties that commissioners will have in the future and suggests that commissioners will need to seek advice, but what kind of advice is not clear. GPs will need to work closely with their clinical colleagues in different specialisms, particularly specialists in mental health, to ensure that their patients with mental illness get their ordinary, everyday healthcare needs supported and adequately met, and not just their specialist needs.
People who do not work in psychiatry often think that commissioning for mental illness or learning disabilities is about buying specialist services somewhere else and that it has nothing to do with the rest of the health system. That is just not true. There is no health without mental health and I am pleased that the Government's policy on public health acknowledges that.
Because I have less than a minute, I shall turn only briefly to learning disability. Tom Clarke MP spoke in the other place yesterday about the NHS and public satisfaction. He spoke extremely eloquently and, since I do not have time to repeat all that he said, I encourage noble Lords to read Hansard. He talked about the long history of concern of Mencap and other bodies about the institutional discrimination that has been found in the NHS-not a culture of care but a culture of discrimination. The previous Secretary of State
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Lord Winston: My Lords, the points that I shall make are no criticism of the Government; indeed, they are not faults induced by them. If there have been faults, they have been those of healthcare professionals and the management of the health service. I hope that the noble Earl will be able to respond by saying how we can build in these suggestions. This is a strong echo of what the noble Lord, Lord Turnberg, said. He spoke with nobility, dignity and humanity and his points were very well made.
Some weeks ago, I brought to the attention of the House my experience at a leading hospital, where I was faced with a woman in her postnatal period, four days after delivery, with a dangerously high, life-threatening blood pressure, which no one was dealing with-she had not seen a doctor in four days. There was no continuity of care on the ward. When I tried to speak to the nurses, they were busy at their computers and with their paperwork.
I want to talk about the loss of continuity of patient care in the hospital service. The noble Lord, Lord Turnberg, talked about halcyon days. Although we may not want to return to those days, the old-fashioned firm system in medical practice was very good: the idea of consultants working in tandem, usually two at a time with the same secretarial support, followed by a senior registrar, a registrar, house physicians and house surgeons, was a good way to ensure continuity. Nowadays, we do not even have the privilege of interviewing the staff who come on to the team. Because of political correctness, they are often appointed. That means that we lose a valuable kernel within the health service.
There used to be flexibility about time off. We did not go off when a patient was really sick. We had a detailed handover when we went off, if we had to. We would make sure that the person to whom we were handing over understood what was going on. We were still responsible, as junior doctors, when we were off, and would expect to be informed if critical decisions were being made about those whom we regarded as our patients. That ethos and that culture have been lost, partly because of the European working time directive, although that is not the only reason. The restrictions on working time, which we have previously encouraged the Government to think about, have had a massive negative effect not only on training and experience but on morale and continuity. A "watch the clock" attitude has been engendered.
There used to be general ward rounds for the whole team, at which the ward sister would be an important person, together with the general practitioners. Often, general practitioners came to the wards, which meant continuity in society afterwards. Nowadays, we do not have the same attitude towards the hospital in which we work. We have no hospital nurse, no medical porters and no dedicated bedrooms. There is no staff
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As the noble Lord, Lord Turnberg, said, there is no leadership on the ward. Without ward sisters, individual nurses do not feel responsible for all the patients in their care on the ward. Doctors now normally do ward rounds without the sister present; indeed, it is difficult to find a nurse who is free.
I make one final point. Basic nursing has been lost: cleaning patients, caring for them, listening to them, trying to feed them occasionally. Yesterday, I met a paediatric nurse at one of the best nursing schools in the country. She said: "I got an A in hospital management and NHS management in my essays, but I cannot change a paediatric colostomy bag, and that really worries me".
Baroness Benjamin: My Lords, I thank the noble Lord for securing this debate. Sadly, his opening remarks reflect the treatment that my late 80 year-old father received during his last months, which were spent in hospital.
This debate gives me an opportunity to highlight the concerns of those with sickle cell disorder as well as of those working with and for patients with the disorder. I am a patron of the Sickle Cell Society, so I declare an interest. The Sickle Cell Society has a panel of expert medical advisers as well as a board that includes those who suffer from sickle cell disorder. Over the past 30 years, the charity has worked with the NHS and primary care trusts to produce best practice guidance on treatment and care based on clinical research and the experience of those with sickle cell disorder.
Sickle cell is the most common genetic blood disorder in the UK and some 300 babies are born with sickle cell each year. Yet children and adults are needlessly dying from this illness. The two most recent deaths were in the past four months-one as young as four years old. The deaths are due to poor access to services, poor care, poor treatment and generally poor awareness of the disorder. The National Confidential Inquiry into Patient Outcome and Death shows that of the 19 patients it studied who complained of pain on admission to hospital and who died in hospital, nine had been given excessive doses of medication, leading to death from the complications that resulted.
I believe that with the right policies in place and an understanding of best practice standards, treatment and medication, the quality of life for sickle cell patients can be dramatically improved. Will the Minister consider a medical and social awareness campaign, backed up by syllabus changes to medic training at royal colleges? Will he also consider commissioning services to improve the detection and chronic disease management of patients
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I believe that the doctor-patient relationship is a two-way dynamic. Some changes to the current system are required in terms of GP education, follow-up, and long-term involvement with the management of sickle cell disorder. Patients and healthcare providers should work together in the proactive management of sickle cell disorder, rather than dealing with crises on an unplanned basis as and when they arise.
The current financial state of the NHS and the recent spending review have increased the nervousness of sufferers. Therefore, there need to be reassurances about the funding of provision for sickle cell. Some believe that the abolition of health targets will have a negative impact and that services will not provide fairness and equality of access to healthcare services for all. Therefore, there needs to be NHS specialised services commissioning for those with sickle cell disorder, with provision for practical home-care support, especially home-from-hospital convalescent support to avoid readmission, the training and deployment of a pool of community support care workers, information and counselling to every patient and carrier in every locality, and the monitoring of performance against agreed outcome measures. I believe that the Sickle Cell Society is well placed to assist the Government in achieving these measures.
Sickle cell disorder should be of great concern to society. It needs our full attention because as more and more children are born to parents from different ethnic groups and we become more and more integrated, so the more common sickle cell disorder will become. Sickle cell disorder is now the fourth global public health priority, as declared by UNESCO and the World Health Organisation in Geneva in May 2006. Please let us accord it the priority and respect it deserves.
Baroness Murphy: My Lords, I shall hark back to much of what the noble Lord, Lord Turnberg, said in his admirable introduction to this topic. The stories in the ombudsman's report are so shockingly familiar to us, yet we still find it very difficult to take in that they reflect the norm. The National Confidential Inquiry into Patient Outcome and Death in surgery for elderly patients found that only 38 per cent got good care. It is not just that care is neglectful to the point of cruelty, but that families that try to intervene are actively discouraged and largely ignored and the denial by managers is a cultural norm. I found that I could not save my own mother-in-law from truly appalling care in a suburban London hospital, and my own mother's recent care in a Midlands teaching hospital was pretty variable, too, depending on the team that was on duty.
I have heard people minimise the significance. Apparently the NHS has improved over the past few years and patients say that they are very satisfied with
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The usual response to a scandal is to launch an inquiry, and I have sat on many myself. Typically they make vast numbers of recommendations that are then translated into points for action with a monitoring schedule for ticking off the boxes. Schedules will be cascaded and all will get a bit better. There are marginal improvements locally, but nothing really changes. What is the answer? More inspection? I do not think so. The CQC knows that the self-monitored standards of dignity that hospitals claim to have reached are often a fiction. Inspection never picks up more than a snapshot. Unannounced visits are helpful, but they are too infrequent and superficial to be realistically helpful. Regulators simply cannot substitute for caring staff. More training that treating old people appallingly is wrong? I do not think so. We all know it is wrong, but we learn by example from our seniors. If that counts as training, then perhaps training is needed. More geriatricians and psychogeriatricians like me? We need champions in medicine and nursing-but no, this is every clinician's business, not a specialty.
I agree with many colleagues who have spoken before that getting the teamwork and ward processes right might help a bit. It is noteworthy that these episodes of poor care do not occur on specialist wards where unified teams work together under good leadership. We have tended to undermine teams on general wards in the misguided and counterproductive chase for efficient turnover. I harp back to Professor John Yates's earlier studies, which show that it is vulnerable patient groups, local ward staff left to their own devices and staff not included in team support who fail.
My recipe comes back in part to unannounced regular inspections by HealthWatch and the regulator and to surveys of family carers. However, hospitals reflect the wider attitudes of society. We should look properly at the price of care, and we should stop commissioning specialties such as cardiac, cancer and renal at a higher tariff on the care price compared with medicine for the elderly and general surgery. The funding imbalance is profound and reflects the poor value which society puts on the everyday care of the most vulnerable. Therefore, the commissioning sensitivities that GP consortia will have will be crucial. We know from studies in the States that commissioning cannot be the whole answer; it is the providers who are important. However, we should not necessarily ignore commissioning. It is vital, but ultimately it is the care design in hospitals and structures that really count.
Lord Owen: The NHS is dear to us all, and the care and health professions have made a difference to pretty well every family in this country. However, the 353 pages of the Health and Social Care Bill are a massive
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The health service is a rationed service. A lot of the acceptance of and satisfaction with that rationing has come from its democratic basis and the feeling that it is done in a democratic and acceptable way. That is challenged by the Bill and by a massive change in the responsibilities of the Secretary of State. The fatal flaw is to move on from the internal market-a reform introduced by successive political parties that was initially quite controversial but, I believe, has done a lot to encourage cost-effectiveness and efficiency in the health service-and to cross that threshold to an external market.
This Bill needs to be substantially amended, not just at Report stage in the other place-it has not yet been amended in Committee-but when it comes to this House. In my view, it is not in the interests of anyone to include "any willing provider", which would inevitably involve EU competition law and legal cases about commissioning decisions. Nor is it in anyone's interest that we should make costs and pricing the basic decision on where a patient is allocated. That would have profound effects on the relationships between patients and the general practitioners, consultants and managers who have to make these rationing choices.
Deep and fundamental problems underlie this Bill. I hope that when it comes to this House we will use the unusual but nevertheless precedented position of giving it a Second Reading but only on condition that it is referred to a Select Committee of this House in order to give it far deeper and more fundamental attention. This Bill should have had a full pre-legislative committee. It has not got it. Listening to this debate, it seems to me that we are not reflecting the anger, disillusionment and despair of many people outside this House about this legislation. Were the Bill to pass in its present form, it would do horrendous damage to the health service-not immediately, but slowly and imperceptibly. It would also damage the professionalism, care and intimacy of the one-on-one patient-nurse and doctor-patient relationships, which I believe are so essential.
Health is not just a commodity to be bought and sold in the market. It is not a utility in which everyone should be treated as if they are commodity managers. We must understand that and the fundamental issues which are being challenged by this Bill. Perhaps they are being challenged inadvertently but, nevertheless, that is happening. Extensive amendments have already been talked about. Why was the Bill in that condition? I urge this House at Second Reading to refer it to a Select Committee-perhaps for six months until after the Summer Recess. Then we could come back to the normal amendments and, if necessary, the ping-pong between both Houses. Ultimately, I would not hesitate to delay this Bill for the statutory period if the House of Commons does not accept amendment procedure in this House. Fundamental amendments are needed. This is not a minor piece of legislation or a part of the evolutionary change we have had since 1948; it is a revolutionary change and, in some parts, a very bad change.
Baroness Pitkeathley: My Lords, I thank my noble friend Lord Turnberg and declare two interests as chair of the Specialised Healthcare Alliance and as chair of the Council for Healthcare Regulatory Excellence.
However devoted we are to the NHS-I speak as one who owes her life to it-we must acknowledge that there are still far too many instances where it falls short. No one could fail to be shocked by the ombudsman's report to which many noble Lords have referred. The universal standards which we all wish to see, of a compassionate and skilled service, are by no means universal as yet. The dismissive attitudes and indifference to deplorable standards encountered in all too many instances must be addressed and, as far as possible, eliminated. I say "as far as possible" because, as a regulator of healthcare, I know only too well that it is not possible for any form of regulation to bear on every safety or quality concern. We are dependent on the quality of the professionals delivering the service and we must judge this always from the experience of the patient and his or her family.
When we think about commissioning as being about improving health outcomes and reducing health inequalities, let us never forget what that means from the patient's point of view. Most will have absolutely no idea what "improving health outcomes" means. They only know that they want to be treated safely, with dignity and compassion, and have timely and effective treatment. In all the discussions we are currently having about the reform of commissioning, I am often struck by how remote those discussions seem from the actual experience of patients. The test that we must apply is whether it is better for them, not whether it is better for the Secretary of State, the commissioning board and GP consortia.
It is also striking how removed our discussions are from the facts around patients' experience, which are not linear but confused and complicated-a mixture of services from health, social care, housing, the voluntary sector and their own families. This complication of experience is little recognised, even now when some of us have been trying for 30 years to get it recognised. The question we have to ask is: will the new commissioning arrangements deliver that recognition? We do not know.
What we do know is that every bit of research ever done about changing institutional structures shows that only a part, and usually a small part, of the objectives are achieved, and the bigger the upheaval, the fewer of those objectives are achieved. Since we are largely dependent for quality outcomes on the skill, commitment and-let us not be afraid to use the word-dedication of our staff, how are we to maximise those and provide them with the support they so urgently need when, for the next two years at the very least, their energy will be directed towards the change itself in the form of applying for their own jobs, learning to work with a new set of partners and so on? Also, the history of co-operation between GPs and social services does not fill me with hope, while the lack of co-terminosity between consortia and local authorities is certainly not going to be helpful.
We know that the commissioning board will issue guidance on commissioning to the consortia, but when is this to happen? Do we not risk a mismatch in timing? Some of the consortia are already willing to go ahead and are following their own rules in the absence of any from the commissioning board. I hope that the Minister will be able to comment on this. Also, from the patient's point of view, we need a great deal more clarity about what will happen when GP consortia refuse to commission a service that a patient requires. Where is the accountability?
As to the voluntary sector, for so long the provider of good preventive care and services, we hear a great deal about organisations being encouraged to take on a greater share in providing public services and for the commissioners to recognise this. If we are serious about pushing power as close to individuals as possible and for citizens and communities to define the priorities and expectations of public services like the NHS, as the big society concept suggests we should, it is certainly important for the voluntary sector to be involved. However, many organisations are having their funding savagely cut, and more than half of them say they are going to have to cut staff in the next three months. Given that, I doubt their capacity.
Lord Rooker: My Lords, there is widespread concern among nurses, patients and relatives about the many incidents of poor nursing highlighted in recent years. There are of course many fine examples of high-quality nursing practice, and I can testify to that from my own family experiences. But action now needs to be taken to improve the state of nurse training and management. Over the past five years, a nurse friend of mine, Sheila Try, has been contacting successive Health Ministers, Select Committees and others with these concerns, as well as the Chief Nursing Officer, all to no avail. They have all failed to see that there is a fundamental flaw in the training and management of nurses and that the image of nursing has been damaged. The Chief Nursing Officer commented to Sheila that these,
Sheila Try is a qualified nurse and a health visitor to BSc standard, and a former senior manager and a reviewer for the Commission for Health Improvement. She is not someone who wants to turn the clock back, but she is concerned with the basic essentials of nursing. Last week, she met over 70 third-year degree nursing students at a local university who are due to qualify in August. They stated that they,
The students are concerned that their competencies are usually decided on just one observation of the skill required, such as catheterisation or wound care. They would prefer a more rigorous check in order for them to feel competent and confident. On learning to drive with an instructor, you do not do a three-point turn only once.
One of the issues lies in the ratio of academic to clinical practice. The time spent in contact with patients is only 15 weeks in each of the first two years over two placements and 21 weeks over two placements in the final year. That is not enough. This is not resulting in well trained nurses capable of giving good, consistent quality care at the point of qualification.
Image and esteem are important. These have been damaged by the practice of not using the title of "nurse" and the poor national uniform that was introduced some years ago. After working for three years to become a nurse, people are told not to use the title, but to tell patients their first name, which is unprofessional. The sign above the bed says, "Your nurse is Susan" or "Mark", but not "Nurse Jones" or even "Nurse Susan". That is ridiculous because it is unprofessional and breeds a familiarity that can cause problems.
The uniforms that nurses wear in most hospitals are not very professional, with qualified nurses wearing the same uniform with no difference in design to identify their status. The uniforms are often of poor quality. Nurses have said that they are more like a cleaner's overalls-that is not to degrade cleaners. This affects not only the image that the uniforms portray to patients and relatives but also how nurses feel about themselves.
One major hospital in the Midlands has recently changed its uniform policy, bringing in colours to identify a nurse's grade and with the grade embroidered on the uniform. Patients and relatives can now distinguish between a staff nurse and the sister in charge. It has massively lifted morale, because the nurses feel valued. The ward management points that Sheila has asked me to make are exactly the same, word for word, as those made by the noble Lord, Lord Turnberg. The solution, she thinks, is simple: tackle the way in which nurses are trained, with more time spent with patients and less in the classroom.
Nursing needs to be up to date with technology and the changing face of disease and management, but essential care is vital to ensure patients' safety. A better balance between academia and professional placements, needs to be found. And, yes, Nurse Try would welcome an opportunity to put the case to the Minister direct.
Baroness Tyler of Enfield: My Lords, that is a hard act to follow. I congratulate the noble Lord, Lord Turnberg, on securing such an important debate at a time of far reaching reforms to our National Health Service. These reforms should be judged by the extent to which they lead, first, to better health outcomes for adults and children; secondly, to consistently higher standards of care for all; and, thirdly, to a more responsive and personalised service. Given the scale and pace of reforms, the most radical in a generation and beyond, it will be crucial to give close attention to the quality of care during this period of immense change.
I would like to illustrate this by talking about the standards of care and commissioning practices within mental health services, still seen in some quarters as a Cinderella service. I am indebted to the briefing and support that I have received from the charity Mind.
One in four people is likely to experience a mental health problem every year and the cost of poor mental health to the economy is estimated to stand at £105 billion. As will be well known in your Lordships' House, mental health problems are inextricably linked to social factors such as debt, unemployment, poverty and poor housing.
The Government's recent No Health without Mental Health strategy sets out a clear vision for the future of our mental health services. This is to be welcomed. The strategy also makes it clear that the provision of high-quality services is dependent on high-quality commissioning.
To make a reality of that strategy, it will be important to ensure four things: first, that commissioning bodies have a proper understanding of mental health services and service users; secondly, that mental health services are fully integrated both within the health service and across social care, public health and areas such as housing and policing; thirdly, that every opportunity is taken to increase patient and public involvement and that those who need extra support to get involved in decision-making are given it; and, finally, that there is parity of esteem between mental and physical health services.
In response to a recent survey by the charity Rethink, 42 per cent of GPs said that they lacked knowledge about services for people with mental illness and lacked confidence in commissioning those services. The abolition of the National Mental Health Development Unit this very day will create a real gap in mental health advice for commissioners and providers. What plans do the Government have to fill that gap in expertise?
The Government have recently announced plans to invest around £400 million over four years to ensure that adults with depression and anxiety across England have access to a wider range of effective psychological therapies. This investment will also enable the expansion of much needed psychological therapies for young people, older people, people with severe mental health problems and people with long-term physical health conditions. All this is greatly to be welcomed but it is vital that this funding is not seen in these tough financial times as an opportunity to cut existing mental health services.
As already referred to, only this week the Care Quality Commission released its latest report on the state of health and adult social care. I was concerned to see that, despite the welcome advances across the board, care standards for people experiencing mental health problems are being left behind, particularly in acute and crisis mental health care.
I would have liked to have finished by saying a few more words about the commissioning of children's mental health services-an area that I know something about. I am chief executive of the charity Relate, a declared interest of mine, which has experience of providing what is called early intervention counselling services. Time will elude me, but the one thing that I will say is that far too often the voluntary sector finds
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Lord Touhig: My Lords, I join others in the House in thanking my noble friend Lord Turnberg for securing this debate. In the short time that I have at my disposal, I would like to focus my remarks on one area in particular: healthcare and autism. The noble Baroness, Lady Browning, and I, together with representatives of the National Autistic Society, recently met the Minister and we were given a very sympathetic hearing on matters that concerned us. We thank him for that.
The National Audit Office's investigation into public spending on autism found that one of the best ways of overcoming the alarming gaps in training, planning and provision across a range of services was to develop specialist autism teams that could diagnose and support people with autism. It went on to say that, if such teams are established, there is the potential to save money. It stated that, if local services identified and supported just 4 per cent of adults with high-functioning autism and Asperger's syndrome, the outlay would become cost neutral over time. In addition, it found that, if these local services did the same for just 8 per cent, the Government could save £67 million per year. The Liverpool Asperger Team, which is the longest-standing specialist Asperger's service, reports an identification rate of 14 per cent, so 4 per cent is certainly achievable.
Will the Minister tell the House how teams such as the one in Liverpool will be funded if the Health and Social Care Bill is passed into law? In the Bill, health and social well-being boards have a duty to promote integrated working and, as such, would lead on commissioning specialist services. However, the White Paper published in July states that the NHS Commissioning Board will take responsibility for commissioning specialised services at both national and regional level, as informed by the specialised services national definitions set. These sets contain definitions of 34 services. Definition 22 covers specialist mental health services and includes specialised services for Asperger's syndrome and autism spectrum disorder. There is clearly a difference between the White Paper and the legislation on how specialist autism teams will be commissioned to carry out their work. Will the Minister say whether the NHS Commissioning Board or, at local level, the health and well-being board will be responsible for this commissioning work?
Each of the commissioning scenarios is not without problems. First, specialist teams are often commissioned through pooled budgets. There is concern that, if 80 per cent of the commissioning budget sits with the GP consortia but the health and well-being boards are responsible for commissioning the joint services, the major budget holders-the GPs-may not commission services whose primary benefit in the short or medium term will be the local authorities. The commissioning problems could potentially become more complicated when health and well-being boards have a number of
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The draft NICE guidelines on diagnosis, recognition and referral of autism in children and young people call for local teams to be created in each area. Teams such as the ones in Liverpool and Bristol are doing first-class work. A key way of getting over this problem of commissioning specialist teams is to strengthen the role of the health and well-being boards in creating pooled budgets and to ensure that the NHS Commissioning Board can intervene in any disputes over these budgets. I appreciate that this is a major problem still to be solved and I hope that the Minister will respond to that and to my other questions.
Lord Patel: My Lords, good healthcare systems deliver good standards of care and good commissioning should reflect that. I would like to focus on cancer, the insights that it offers into the performance of our healthcare system and the challenges that it poses in the new healthcare structure. The proportion of deaths attributable to cancer has risen from 17 per cent in 1948 to 27 per cent in 2008. It is predominantly a disease of the elderly. Alongside its human impact, cancer is also costly. The National Audit Office estimates the cost as £6.3 billion and the total cost to society as £18.3 billion. These costs will rise as the population ages and new treatments are developed.
Cancer survival is a key metric of the performance and quality of healthcare systems. It is a function of the population awareness of cancer symptoms, primary and secondary care assessment and referral, treatment quality and effective screening programmes. Each year around one in three people is diagnosed with cancer and one in four will die of cancer.
The Lancet in January 2011 compares the survival of patients diagnosed in England, Wales, Northern Ireland, Denmark, Norway, Sweden, Australia and Canada. All these countries have comprehensive cancer registration and broadly similar healthcare spending and systems. The study examined relative survival-the excess deaths due to cancer after allowing for competing causes of death-from 1995 to 2007. Despite the improvement in cancer survival in the UK, the survival gap-the difference between the UK and the best-performing nations-appeared to have showed only some narrowing in breast cancer but was static in colorectal and ovarian cancer and worse in lung cancer. The difference in survival in lung cancer is equivalent to at least 1,300 avoidable deaths each year if we matched the best in Europe. It has been estimated that this survival gap from England to the best-performing countries in Europe for all cancers accounts for 10,000 avoidable cancer deaths each year.
The healthcare system in the UK is not improving at a fast enough rate to narrow the survival gap. This accounts for thousands of avoidable deaths each year. A far greater proportion of people die within one year
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The coalition Government published in January Improving Outcomes: A Strategy for Cancer. This strategy aims to deliver health outcomes that are among the best in the world. It aims to do this alongside the seismic reforms that are taking place in healthcare in England. These new reforms as they stand rely on high-quality information and organisation of cancer services. The strategy does not ensure the continued existence of cancer networks, but says that,
That does not go far enough. Cancer networks are essential organisations to ensure the delivery of improved cancer outcomes and, in particular, the geographical areas that allow robust outcome data to be derived. The centralisation of cancer services since the NHS cancer plan has helped to deliver improvements in cancer outcomes. The National Cancer Intelligence Network is now providing detailed cancer outcome data according to network, PCT and age. These powerful data can be used to improve outcomes.
Much of the variation in outcomes in cancer is due to late diagnosis or referral by general practitioners. There is no process in place for assessing the quality of GPs in the assessment of patients with potential cancer symptoms. The Teenage Cancer Trust survey reveals that one in four teenage cancer patients visited their GP four or more times before referral to hospital. Without cancer networks, there is a danger that the cheapest services will be purchased that meet basic but not world-class quality standards. Healthcare is a complex process and we will never be able to define and record every metric that will contribute to high-quality outcomes. I hope that the Minister will confirm today that there are no plans to abolish the cancer networks.
Lord Warner: My Lords, I am grateful to my noble friend for securing this warm-up debate before the Government's legislative juggernaut reaches this House. In the time available, I want to confine myself to talking about commissioning because good commissioning has a significant impact on achieving good service standards. For 20 years, we have been trying to establish an effective NHS commissioning system. Ken Clarke's GP fundholding and partial purchaser/provider split was followed by Labour's PCT commissioner model, again without a full purchaser/provider split. Just for good measure, I added on a practice-based commissioning dimension in 2006 which many PCTs were pretty effective at thwarting. Now we are to have another legislative go. That is a summary of the history of commissioning.
All too often, PCT commissioners have lacked the know-how, competence and muscle to commission effectively. Too often, they have been unable to manage demand, keep in check acute hospital expenditure and hold hospitals to account. We know from the Care Quality Commission data that there are too many PCTs with poor track records on quality and financial
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The population size of many commissioning bodies has been too small for effective health-risk pooling. When I hear the BMA say that there is a new commissioning consortium with a population of 18,000 people, I despair. I managed to reduce the number of PCTs from 302 to 150, but could not secure agreement politically to go down to 50. That would have given us commissioning bodies with populations of about half a million to 1.5 million people. I believe that is the kind of population we should be looking for in commissioning the full range of services that the Government wish to give to those kinds of consortia. The amount of high-quality commissioning capability in the NHS that we had in 2005 was insufficient to service the number of bodies involved. That remains the case today and the added trouble is that the amount of money available to pay for them has become even smaller in size.
When the Bill comes to this House, we are going to have to probe the area of commissioning forensically. We will need to ensure that there is a proper system of licensing or accrediting commissioners, however the function is organised. We need to ensure that commissioning bodies have the data collection and the analytical, financial, contracting and clinical expertise to commission safely and cost-effectively the range of services that they will be legally required to commission with about £60 billion of public money a year, on present estimates. The National Commissioning Board must have the authority and capacity to prevent people without the competence to commission getting their hands on big slugs of public money. The board has to be able to remove and replace inefficient, incompetent or overspending commissioners in a timely way. Those are the kind of issues we should be considering when we come to that Bill.
In conclusion, as a former commissioner of social care I found it jolly useful to have a diversity of service providers so, unlike a number of people, I congratulate the Government on going for a bit more competition and extending the market for providers-not just from the private sector but with good providers from within the NHS and good mutuals, of which I suspect we will see a lot more in future. We will have a lot of time to discover what the Government's thinking is on some of these issues as we take the Bill forward in this House.
Baroness Thornton: My Lords, I start by thanking my noble friend for initiating this debate and for emphasising the importance of standards of care and of the effect on patients of the proposed changes to
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I welcome the noble Lord, Lord Owen, to both this debate and our wider discussions. I look forward to reading his pamphlet, Fatally Flawed, this weekend, and I suggest that the Minister might choose to do the same. However, I will resist the temptation to join the noble Lord in what would be a Second Reading speech.
I start by quoting a young woman who works in healthcare and who spoke last Saturday to between 200,000 and 500,000 people-personally, I think it was nearer the latter. In many ways, her simple eloquence says it all about how thousands of dedicated health workers feel. She said: "I am an NHS physiotherapist and have been for 13 years. My patients are people living with complex disability from conditions such as MS, brain injury, spinal cord injury and stroke. I work with a wonderful team of NHS workers such as occupational therapists, speech therapists, psychologists and rehab assistants, as well as social workers, to support our patients to overcome barriers to their independence, often supporting them back to work and working with their carers to support them to stay in their homes for as long as possible ... David Cameron told you all in his election campaign that he would 'cut the deficit, not the NHS'. Well, if 50,000 frontline NHS posts at risk doesn't count as a cut, I shudder to think what does ... For the sake of my patients, I fear the introduction of 'any willing provider'. I fear that it will fragment services, will make the postcode lottery of care worse, and the most vulnerable patients, those least able to stick up for themselves-the kind of patients I treat every day-will be hit the hardest. Good quality patient care relies on good communication. How can we guarantee this, when services that currently work together are pitched into direct competition against each other? ... In parts of the country, physios are already starting to see the rationing of care to just one or two treatment sessions, regardless of need ... This is not the NHS I signed up to work for. I don't believe it is the kind of NHS that people in this country want".
In this short response to the debate I am going to argue that we would not start here with reform and I will ask some questions about the risks to standards of the proposed commissioning system. I put a plea to the Minister: could we perhaps have some new words in his answers to these debates? I have looked back at the debates and discussions in the House since the White Paper was published last July, and time after time the Minister has stuck admirably to the Andrew Lansley brief, with what is becoming the famous NHS techno-jargon that weaves a web of words but really does not serve to comfort, or even leave one any the wiser. It is very noticeable that when the Minister comes off script and is back to his old, clever self, we prefer it and I, for one, understand things better.
We are nearing the point, after many questions and sustained criticism from professionals, patients and even the Minister's partners in the coalition, when we need some real answers to real concerns, not least on the commissioning that is the subject of this debate. Notwithstanding the progress of the Health and Social Care Bill, I invite the Minister to agree that there is no doubt that the period 2011-14 is likely to be the most challenging ever faced by the NHS. The NHS is faced with the challenge of producing £20 billion in efficiency savings, putting considerable pressure on the system to maintain current standards of care. Given those constraints, we on this side of the House are still of the view, perhaps even more so now, that this is not the right time to embark on the largest structural reorganisation in NHS history, which includes scrapping those layers of the NHS structure with real experience of commissioning-family care trusts and strategic health authorities-and putting the power in the hands of untested and inexperienced consortia.
I am not saying that PCTs and SHAs have been unfailingly brilliant; in some cases, they have not even been good or average. There was and is significant room for improvement, and I think we would all agree on that. Most notably, clinical leadership and engagement in PCTs has often been weak, local accountability has been lacking and imbalances in status and power that exist between commissioners and providers appear to have limited substantially the former's ability to influence service provision, to say nothing of the lack of clinical presence in the whole process. However, we believe that it would have been better to tackle this problem rather than to turn the whole NHS upside down.
What of the transition? Responsibility for maintaining and improving the quality of services will fall initially to the new PCT clusters. At a time of major reorganisational transition it will be especially important to have in place adequate performance measures supported by transparent and robust mechanisms, through which the GP consortia and PCT clusters can account to local people for the quality and performance of local health services. I do not see how this can be achieved when PCTs are being decimated either by the efficiency cuts or people jumping ship to work elsewhere. Perhaps the Minister can say how he thinks this will be achieved.
We know that PCTs are responsible for commissioning a range of primary, community, secondary and tertiary health services, often in partnership with local authorities-for instance, in mental health-and, indeed, other PCTs, through networks or consortia for specialised services, and primary care clinicians through practice-based commissioning. That has already been mentioned by the noble Lord, Lord Patel-cancer networks being one of these. This is a complex landscape and it is about to become even more so. It will grow a whole new bureaucracy of its own if the competition which the Government intend to put at the heart of the Bill, whatever one believes about that, is as envisaged.
The majority of concerns with the health Bill in relation to commissioning of services fall into five broad areas: multidisciplinary commissioning; commissioning of long-term conditions; specialist commissioning; a lack of national guidance leading to fragmentation; and communication and co-ordination between providers
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The King's Fund report of the beginning of March highlights the need for strong, strategic commissioning to reconfigure some services such as cancer, cardiac and stroke care across large geographical areas. It argues that this will not be delivered by the Government's health reforms, which will abolish the strategic health authorities currently responsible for leading this work and leave GP consortia to fill the gap, which they are unlikely to be able to fill-to which I add that that will probably be the case for at least 10 years or so.
Briefly, on long-term and specialist conditions, throughout the debates since last July various advocates and campaigning organisations on almost every long-term condition have commented on the proposed reform. The Minster must accept that the Alzheimer's Society, the cancer campaigns, diabetes organisations and many others are very worried about the commissioning for their conditions becoming fragmented and incoherent, to say nothing of end-of-life care and, for example, treatment for children with very serious conditions.
The Government are asking those who have fought long and hard for recognition of and improvement in the treatment and care of people to take on trust that everything will be okay. The Minister needs to accept that this clamour about commissioning, although we are joining it, is not motivated by Her Majesty's Opposition being oppositionist; it is about a long list of concerns, questions and anxieties that we have to address without the proposed revolution. I look forward to the Minister's reply.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe): My Lords, I begin by thanking the noble Lord, Lord Turnberg, for tabling a Motion which has occasioned such a fascinating and often moving debate. As has happened previously, the breadth and depth of the contributions create their own problem in that, when there is such a short time available for me to reply, I am up against the clock. To the extent that I am unable to answer specific questions today, I apologise but I will of course happily follow them up in writing.
There are many reasons why we believe it is necessary to modernise the National Health Service. With rising costs of new treatments, an ageing population and rising public expectations, the system is simply not sustainable in its present form. Most importantly, however, the NHS must modernise in order to focus relentlessly on what matters most to patients: improving health outcomes. In so many ways it is a wonderful service, but we know that it can do better and we believe that it must do better. For our ambition is not limited to maintaining the current quality of services, it is far greater-to have health outcomes that are consistently among the very best in the world. I suggest to the noble Baroness, Lady Thornton, who said that now was not the time to do any of this, that the financial situation that we face provides even more of
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The noble Lord, Lord Turnberg, began by raising the Parliamentary and Health Service Ombudsman's report, Care and Compassion? I am sure that all of us can identify with the concerns that he raised about nurse training and accountability for what happens on the hospital ward. I am sure I was not alone in being very moved by the noble Lord's speech. I fully intend that we should learn from the ombudsman's report, which is why its findings have been highlighted to NHS boards and why the Care Quality Commission will be commencing unannounced inspection visits shortly. However, I also submit that the changes that we are making to the NHS-placing the patient at the heart of everything we do-will help to guard against this happening in the future.
As the noble Lord, Lord Warner, rightly reminded us, effective commissioning is a key piece of the jigsaw. Currently, commissioning decisions are taken by primary care trusts-remote organisations that frankly few people have heard of and fewer still understand. We propose to hand responsibility for commissioning to GP-led consortia. Why are we doing so? It is because GPs and their clinical colleagues are the people who best understand the health needs of their local populations, and, in partnership with healthcare professionals from across primary, community and secondary care, they are ideally placed to design clinical services that provide more effective, integrated and preventive care.
Lord Davies of Stamford: I am very grateful to the Minister for giving way. Will the present system of "choose and book", which seems to me to be working extremely well, be perpetuated under the new commissioning consortia regime?
Those who question the effectiveness of these arrangements should focus on the new framework of accountability that we are proposing as it is central. The new NHS will be more directly accountable than it is now. Because of that our reforms introduce a stronger national framework for driving quality improvement than ever before. How will this accountability work? The Secretary of State will hold the NHS Commissioning Board to account for delivery against the NHS outcomes framework, published in December. The NHS Commissioning Board will then hold individual consortia to account for their performance against the indicators set out in the more locally focused commissioning outcomes framework. There was widespread and strong support for such a framework during our consultation.
The NHS Commissioning Board will decide on the shape and content of the commissioning outcomes framework over the next two years, working closely with emerging consortia and with professional and patient groups. To help maintain momentum, the department will shortly publish a discussion document, seeking more detailed views on possible features of the
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How will quality be driven through the commissioning system? Quality standards, prepared by NICE, will be at the centre of it. Quality standards bring clarity to quality, providing definitive and authoritative statements of high-quality care, based on evidence of what works best. Quality of care does not cover just the effectiveness of that care but also includes patient safety and patient experience. The three domains of quality are interconnected: they cannot exist in isolation. The Royal College of Physicians reflected on this point in its response to the consultation on the NHS outcomes framework and acknowledged that healthcare that is not safe could not be described as efficient, effective or sustainable.
Our reforms will allow a re-established NICE to produce a broad library of quality standards that will cover the majority of NHS services. NICE will also develop quality standards for social care and public health. The Secretary of State and the NHS Commissioning Board will be able to commission quality standards jointly, which will open up the opportunity for standards to cover the whole care pathway, from public health interventions in primary care through to rehabilitation and long-term support in social care, and will support the integration of health and social care services. It is important to understand that quality standards will do more than just bring clarity to quality: they will have real traction within the system, underpinning the duty of quality and linking with the new best practice tariffs that will see providers paid more for better care.
GP consortia will have a duty to support the NHS Commissioning Board in continuously improving the quality of primary medical care services. That does not alter the board's overarching responsibility for commissioning GP services and holding GP contracts. But it does mean that consortia will play a systematic role in helping to monitor, benchmark and improve the quality of GP services, including through clinical governance and clinical audit. It means also that consortia will have a core role in improving patient care across the system. That will include both the quality and accessibility of the care that GP practices provide and the wider services that consortia commission on behalf of patients.
Where does the Secretary of State sit in all this? The Health and Social Care Bill strengthens the accountability of the Secretary of State to Parliament for the provision
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Nursing has been a strong theme in the debate. The noble Baroness, Lady Emerton, asked when the Government's response to the report of the commission on nursing will be published. I can assure her that the Government will respond soon to the commission's report and I apologise for not having given her an undertaking to that effect sooner. The noble Lord, Lord Turnberg, and the noble Lord, Lord Winston, raised concerns about nursing standards in hospitals. As they know, we now have matrons in post. They have a specific remit for quality of patient experience and should be accessible to patients and carers. Matrons are directly accountable to directors of nursing, who should present ward-to-board reports. We launched the Principles of Nursing Practice in November last year. This sets out an agreed set of standards and behaviours that were developed by the Royal College of Nursing in association with patient groups. These principles reinforce the NHS constitution.
The noble Lord, Lord Turnberg, asked about the duty of consortia to improve the quality of care for older people. There is no specific duty in the Bill relating to consortia and older people. However, we propose a new duty for consortia to seek continuous improvements in the quality of services for patients and in outcomes, with particular regard to clinical effectiveness, safety and patient experience. That extends to all aspects of care.
The noble Baroness, Lady Sherlock, spoke about the recent King's Fund report. The report highlights particular variation in relation to patient involvement in decision-making, and in co-ordination and continuity of care. It also highlights the need for changes in leadership and culture. We have a strong system of general practice in this country, but we agree absolutely with the report that there is too much variation in quality. This reinforces the case for GP decommissioning, because one of the key aims behind the development of GP commissioning is for consortia to play a central role in helping to reduce variation and drive up the quality of general practice. There will be strong incentives for GP consortia to want to tackle these variations, because with lower-quality primary care one achieves poorer outcomes for patients and one has greater pressure on more expensive secondary care services.
The noble Baroness, Lady Sherlock, questioned whether the Government were allowing enough time to see whether the changes would work. With the introduction of shadow bodies and early implementers, we are allowing almost three years to consult, to dry-run and to put our reforms into practice on the ground, so that by 2013 the new organisations will have had time to secure capability collectively. Therefore, it is wrong to say that the house is being demolished; in many senses, we are refashioning some parts of the existing edifice.
On that theme, the noble Baroness, Lady Pitkeathley, asked how consortia will be authorised, given their different states of readiness. The pathfinder programme is, I think, central to sharing learning across emerging consortia, and it is a crucial part of their development to take on full commissioning responsibilities. Consortia will not have statutory responsibility for commissioning until April 2013, so the intervening period will allow all consortia to be ready by that time.
We listened to an impassioned speech from the noble Lord, Lord Owen, who criticised the Health and Social Care Bill on a number of fronts. Time prevents me setting out a detailed set of counterarguments but perhaps I may just say to him that we have tabled amendments to the Bill that will put beyond doubt that competition will be on the basis of quality and not price. Far from challenging the principles of the NHS, we have consistently made it clear that we are absolutely committed to a comprehensive National Health Service which is free at the point of use and is based on need rather than ability to pay. Nothing in our plans changes that.
The noble Lord criticised the policy of "any willing provider", or "any qualified provider" as we are now calling it, because we think that that is a better description of the policy. The noble Baroness, Lady Thornton, did the same. "Any qualified provider" is about empowering patients and carers, improving their outcomes and experience, enabling innovation, and freeing up clinicians to drive change and improve practice. Introducing a choice of any qualified provider will give patients more control. That is what all the research evidence tells us they want and increasingly expect from the NHS. Why should not someone with MS be able to choose the physiotherapist they want and be treated at the time and in the setting that best suits their need? Why should not a patient, at the end of their life, choose their hospice provider? Patients are already able to choose from any provider that meets NHS standards and prices when they are referred for a first out-patient appointment to a consultant-led team. That was an innovation brought in by the previous Government. "Any qualified provider" will extend that principle to more providers and more services, including social enterprises and charities, particularly in community care. For the life of me, I cannot see what is wrong with that. Money will follow the patient and the choices they make about where and by whom they are treated.
The noble Lord, Lord Owen, indicated his belief that the policies that the Government are advancing will damage clinical professionalism and remove the intimacy inherent in the doctor/patient relationship. I say to the noble Lord gently and with huge respect that I do not believe he has any basis whatever for suggesting that. I would argue, on the contrary, that clinically-led commissioning brings the design of services closer to patients.
Earl Howe: The department has sought legal advice on that point and the strong consensus is that the NHS, as we envisage it initially, will not be subject to EU competition law. It is not at the moment, as the noble Lord will know, although of course the situation can change over time. This is an interesting, and rather esoteric, area of debate but I do not think that it impacts-
Earl Howe: I mean that it becomes rather technical. However, I do not think that it impacts on the central point that I was seeking to make, which was to argue that the noble Lord's contention that the doctor/patient relationship would be damaged does not stand up. To me, the principle of shared decision-making-"no decision about me without me"-will bring about an even closer partnership between clinicians and patients.
The noble Lord, Lord Patel, spoke about cancer services. GP consortia will be well placed to commission the majority of cancer services and GPs have a crucial role to play to achieve earlier diagnosis of cancer. As a first step in relation to cancer services, we will work with GP consortia and pathfinders to identify and provide the sort of data that they will find useful to commission cancer services effectively. We will provide GP consortia profiles of services and outcomes for their local populations-for example, cancer survival rates, the use of the two-week urgent referral pathway, uptake of screening and use of inpatient beds. We will be benchmarking the data against similar consortia so that they will know what needs tackling to improve outcomes in their areas. However, as the noble Lord will know, we have also earmarked a great deal of money to ensure that our plans for earlier diagnosis-giving GPs direct access to key diagnostic tests, for example-will assist in the process. He asked about cancer networks. They have had a crucial role in improving the quality of cancer treatment. I quite agree with him. They have helped commissioners, providers and patients to work together to plan and deliver high-quality cancer services. GP consortia will need commissioning support and cancer networks will be well placed to provide that. The department has said that next year there will be funding for cancer networks to support commissioning.
The noble Lord, Lord Touhig, asked about the commissioning of autism services. The health and well-being board will be the key vehicle by which commissioners and local authorities can work together, ensuring that services that cross health and social care can be effectively commissioned. The noble Lord raised a number of valid points about how these arrangements for autism services will work in practice. I suggest that I cover those in a detailed letter.
The noble Baroness, Lady Hollins, and my noble friend Lady Tyler questioned the ability of consortia to commission mental health. We recognise the need for GP commissioners to collaborate with their clinical colleagues and one of the key initiatives in mental health derives from the new joint commissioning panels set up in partnership between the Royal College of Psychiatrists, the Royal College of General Practitioners, the Association of Directors of Adult Social Services,
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Our reforms are ambitious and challenging but we have been heartened by the enthusiasm that we have found among clinicians, especially among those already taking increasing levels of responsibility through the new consortia. There are now 177 GP pathfinders involving more than 5,000 GP practices, covering more than 35 million people across England. I am confident that by empowering clinicians to innovate and deliver health services we can continue to address the healthcare needs of this country and move towards delivering outcomes that are indeed consistently among the best in the world.
Lord Turnberg: My Lords, this has been a fascinating debate and I am enormously grateful to noble Lords for many outstanding speeches. I have learnt a lot. I am only sorry that we had such a short time-each speaker had only four minutes-but I am constantly amazed at how noble Lords are able to pack in so much useful information in such a short time. The noble Earl, as one might expect, was eloquent and convincing, but it remains to be seen how many he has convinced around the House. I am sure that he is as aware as I am that these are not the last words we will hear on these matters. With those few comments, I beg leave to withdraw the Motion.
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