NHS: Front-line and Specialised Services

Baroness Finlay of Llandaff Excerpts

Thursday 13th January 2011 Lords Chamber

[Baroness Finlay of Llandaff]

My Lords, I am delighted to follow the noble Baroness, Lady Jolly. I welcome her and congratulate her on having made a superb short maiden speech in the time available. She has shown a deep affection and critical praise of the NHS. She brings to us experience from engineering and maths, and the critical thinking from that, as well as extensive personal, administrative and provision experience in the NHS and the voluntary sector. I am sure the Liberal Democrats celebrate her being on their Benches, and we must celebrate her addition to this House.

I speak as a clinician in the NHS, and declare all those interests in so doing. The Government have inherited much from the previous Government. They have inherited the problem of the PFI burden, with high interest rates that will increase the burden on hospitals. This will not go away during reorganisation. They have also inherited, as the noble Baroness, Lady Jolly, has illustrated, very high levels of satisfaction with the NHS as we know it. In 2009, indeed, 64 per cent of the population declared themselves to be satisfied or very satisfied. Even among Conservative voters, the figure was 61 per cent.

The public out there fear the loss of the NHS. They fear the escalating costs that they see in US healthcare. A major concern is the concept of “any willing provider” and its effect on primary and secondary care. The competition engendered by this concept seems to work against collaboration. In private-provider competition there seem to be three main problems. The first one, identified in the US, is fraud. The biggest department in the FBI is that which investigates fraud in healthcare, yet we have US providers advising us. I find that worrying. The second problem concerns the role of Monitor. Will Monitor promote competition? The US system and others show that health outcomes are better where collaboration is higher. I ask the Minister why collaboration between primary and secondary care is not the key marker rather than a pre-requirement to competition. The third problem relates to European law. Current law on services of general intent allow subsidiarity for publicly provided healthcare, but if it is privately provided it will become subject to general interest regulations. If the reorganisation fails, can the service effectively be renationalised?

I turn briefly to financial failure. Current legislation allows for a failing foundation trust to be brought back into public administration, but that will be repealed. What will happen if a GP consortium runs out of money? Will the patients be left with less or no care? I understand that there is to be a central levy to allow for failure. I ask the Minister how it was calculated, and whether the Government are confident that it will be enough to continue care provision, particularly if faced with multiple failures at the end of the financial year. If a GP consortium fails, will it be taken over by the private sector, as is happening with hospitals?

The NHS is there for patients. The phrase “nothing about me without me” is both clever and wholly appropriate, referring to clear simple terms of informed consent, but when transposed to choices in healthcare provider it can become distorted rhetoric. The choices that people have to make relate to decisions across all parts of care: whether to remain at home when ill; whether to have a gastrostomy, as swallowing fails in neurological disease; or whether to try physiotherapy to defer joint replacement surgery. There are decisions about immunisation versus infection risks and about how to manage psychotic disease relapse.

These decisions depend on services being integrated, not operating in isolation or in competition. They require excellence in clinical standards, not just “any willing provider”. The problem is that private providers can cherry-pick services to provide in neat packages, but most patients do not fit neat packages. Choice in packages requires a surplus to choose from, but we cannot afford that. Those with complex co-morbidities are optimally managed by a service leading their care and collaborating with others, avoiding duplication and minimising the risk of patients falling into a gap.

How will secondary care integration with primary care be promoted and long-term planning secured? Patients want choice to be seen by the right person at the right time. Pathfinder consortia may be achieving this in the short term, but if Monitor is to ensure competition, how will such collaboration continue? To ensure data on fair competition, will commercial confidentiality clauses be overturned by statute? How will outcome data be collated? Will they be meaningfully interpreted to account for those with multiple co-morbidities?

I ask the Minister these questions because we are embarking on a reorganisation that will cost up to £3 billion. There is a genuine fear that an integrated NHS is being dismantled under the influence of for-profit organisations.

NHS: Reorganisation

Baroness Finlay of Llandaff Excerpts

Thursday 16th December 2010 Lords Chamber

[Baroness Finlay of Llandaff]

My Lords, like others, I thank the noble Lord, Lord Touhig, for securing this debate at this significant time. Having watched the Health Select Committee questioning yesterday of the Secretary of State for Health, Andrew Lansley, I was left with more concerns than I had previously. As always, the devil is in the detail and the detail is where the problems lie.

The importance placed on the patient voice is welcome, but the new local HealthWatch organisations should have powers to call for an inquiry when there are concerns. Of course, there should be no decision about a patient without the patient being involved in and informed of what is going on. There must be respect for the individual, and provision of care that enhances dignity should be at the heart of every clinician, patient encounter. Attitudes in some areas certainly need to change, both in primary and secondary care, if we are really to have the patient’s concerns at heart. Let us push forward with those measures.

However, my two areas of concern are, first, the “any willing provider” approach and, secondly, the wholesale disbanding of PCTs and the effect on patients of the consequent destabilisation of secondary care. As has already been mentioned by the noble Lord, Lord Hunt of Kings Heath, Chris Ham writes today that,

“what is not yet clear is whether the incentives in the new system and regulatory framework will allow integrated services to grow, rather than stand in the way of their evolution. … We would disagree with the assertion that structural changes will help to meet the productivity challenge and the ambitions of the government’s QIPP agenda. While proposals are being phased in more carefully over four years, we share the concerns set out by the Health Select Committee yesterday, that they will still act as a distraction from delivering the enormous productivity improvements required across the system”.

The “any willing provider” requirement risks fragmentation and cherry-picking, which would leave NHS organisations to struggle to provide for those with multiple co-morbidities and complex needs. The Royal College of General Practitioners and the Royal College of Physicians—I declare that I am a fellow of both—and the King’s Fund and the BMA, of which I declare that I am a member, have all alerted us to the dangers. All support using private and voluntary sector providers to fill the gaps—hospices are a prime example—and to support defined roles. However, hospitals need a critical mass of activity to be efficient. Without that, how will good seven-day cover be achieved?

The Government’s response recognises the fluctuations in need that occur in any one area. Neonatal cots, winter beds and so on are obvious examples. How will flexible provision be achieved if foundation trusts are destabilised by being stripped of their profitable elements by the cherry-picking of private sector providers? Clinicians can tell of many examples of patients suffering when providers are in direct competition and not in collaboration.

The tariffs look crude and contain perverse incentives. For example, specialties that have invested in IT teleconferencing follow-up will not be paid. Clinical leadership in primary and secondary care, underpinned by good management, is overdue, but such leadership must be around pathways of care for patients. That means that secondary care needs to be at the table with primary care, because people do not know what they do not know—advances in different branches of medicine are moving forward so fast that GPs cannot possibly be up to speed with everything. In areas where there are good GPs and good relationships between GPs and secondary care providers, cross-fertilisation will happen but in many areas such relationships are not in place.

What will drive up standards of primary care at local level to ensure that patients with long-term conditions are supported in their own homes? To speak of unscheduled care is to gloss over the reality of out-of-hours work. With only 30 per cent of the week adequately covered, how will the reforms specifically address the needs of patients who want to stay in their own homes? All too often, such patients are put in an ambulance and land in A&E if secondary care provision is not integral to the process of determining pathways of care.

The US model seems to underpin much of the thinking, yet we all know that healthcare per capita in the US is vastly more expensive than that of the NHS despite there being 40 million US citizens without any adequate care. Will the profits from services organised by American systems go to the US? That is not the John Lewis Partnership model, which would reinvest in the NHS.

I turn to PCTs. To have evolution not revolution, why did the Government not put GPs in the driving seat by putting a majority of GPs on the boards of merged PCTs, which could have had a lay chairman? The PCTs could have retained the skills of managers in responding to particular local needs and could have used primary and secondary care working arrangements to make joint plans. If patients can register with any GP anywhere, how will care be provided in the patient’s home when he or she is sicker, older and frailer? Who will want to take on a patient who poses a lot of work? If a GP can jump between consortia, how will stability of commissioning be achieved? Without some baseline stability, quality will not be driven up. We have all seen short-term projects wither. Sir David Nicholson has today exhorted trusts to maintain quality standards. To do that requires stability, not the fragmentation of services.

Many of the partnership agreements between PCTs and local authorities are legal agreements under the Health Act 1999. How will the more than 134 statutory functions of PCTs be discharged? Those include safeguarding children and commissioning for vulnerable groups, prison services and so on. Local authorities are already struggling, so I have no confidence that they will be able to take all this on too. Where will pooled budgets and joint commissioning sit? Will the consortia disband those arrangements, or will they have to respect them and build on them?

With estimates of one in four GPs having a commercial conflict of interest, how will the new model ensure probity in healthcare delivery, given that tendering, done properly, can cost around £500,000? How will the £20 billion saving be found with this massive reorganisation? Redundancies in PCTs are already costing money and losing organisational memory. Staff are then re-employed by private providers. That takes people away from the core task of quality assurance of patient care. The Mid Staffs trust is a glaring reminder of that.

The process seems to be storming ahead, with the detail being clarified as we go. We will be faced with legislation when, as the Health Committee suggested yesterday, the train has left the station at a dangerous speed before we have even had time to scrutinise the Bill.

Hospices and Palliative Care Services

Baroness Finlay of Llandaff Excerpts

Wednesday 15th December 2010 Lords Chamber

[Baroness Finlay of Llandaff]

My Lords, in securing this debate, the noble Viscount has exemplified his tireless work for hospices and is to be congratulated. Hospices’ futures depend on stable funding. The service exists to help people to live as well as possible until their natural death and to support their family, including children.

The report of the Palliative Care Funding Review, which was chaired by Tom Hughes-Hallett from Marie Curie, has drawn heavily on the Welsh model. I declare with a certain pride an interest as the chief architect of that model. We realised that every patient with complex end-of-life-care needs, wherever they are and whatever their diagnosis, should have access to specialist palliative care advice and support to underpin general services in primary and secondary care, irrespective of the bed that they are in, be it at home, in hospital or in a nursing home. We realised also that there will always be some who need to be in specialist hospice beds because they have complex needs. However, the ad hoc way in which hospices have grown up means that some areas have good provision while others remain devoid of it.

We wanted fairness of access for patients, so we developed a funding formula. We calculated that there needs to be one hospice bed or a hospice-at-home virtual bed per 15,000 of population. My rough calculation for England suggests that the numbers are pretty good but poorly distributed. We stipulated the minimum number of specialist staff needed for community palliative teams to oversee hospice beds and for different hospital support teams. This indicated the core service that the NHS should fund, irrespective of provider. If charitable funding dried up, there would still be a core service in every area.

We instigated seven-day working by specialist nurses, costing around £10,000 per team—that was all—with 24/7 on-call consultants to advise any healthcare professional across Wales by telephone or even visit if necessary. In hospitals, these nurses, visiting the wards and sometimes going to A&E, have facilitated discharge to home, and patients have not needed to be admitted. They have also set up home care, so that when the patient gets home everybody is expecting them.

Every dying person with complex needs should know that specialist help is available if needed. Our national standard is that every referral must be responded to within 48 hours. Fortunately, almost all are seen on the same day or next day; a distressed dying patient cannot wait. Direct patient and family feedback provides dynamic quality assessment, while service data inform performance monitoring.

Three years on, we are convinced that per-patient payments will be an accounting nightmare. The complexity is too wide-ranging. Patients need a rapid response and true choice over place of care and hospices need funding stability. End-of-life care cannot be left just to voluntary donation; its commissioning must be a core duty of budget holders.

Health: Passive Smoking

Baroness Finlay of Llandaff Excerpts

Tuesday 30th November 2010 Lords Chamber

[Earl Howe]

My Lords, of course my noble friend is right that there are legal issues inherent in this whole question, which we will look into very closely.

On his first point, it is always a pleasure to hear of someone who has lived a long time in good health despite smoking. However, I say to my noble friend that the Royal College of Physicians estimates that more than 300,000 primary care consultations are recorded each year across the UK for conditions in children due to exposure to second-hand smoke.

[Baroness Finlay of Llandaff]

Given the risk to children that has just been highlighted of exposure to passive smoking, what action do the Government intend to take against smoking in cars—which is a very restricted space, particularly when the windows are closed—and also in schools or among young people generally, so that young people have the courage to challenge when somebody lights up in close vicinity?

[Earl Howe]

My Lords, we have no plans to legislate further for banning smoking in cars. As she will know, when a car is used as a workplace smoking is illegal, but when a car is being used privately that is a different matter. We do not intend to legislate.

On messages in schools, we know that youngsters are concerned about parental smoking. In fact, the younger the child, the more concerned the child tends to be. Schools are encouraged to include advice on smoking in the PSHE curriculum.

Public Health

Baroness Finlay of Llandaff Excerpts

Tuesday 30th November 2010 Lords Chamber

[Earl Howe]

My Lords, my noble friend asked a series of important questions. He has put his finger on how, in many senses, the system will be joined up. He is right to say that Public Health England will be instrumental in supporting local directors of public health in their task. We envisage that Public Health England will create a common sense of purpose and values among a widely dispersed group of workforces. We will develop a workforce strategy with representative organisations and publish that next year. That, I hope, will help to support a smooth transition. At the same time, we do not want to cramp the style of local directors of public health. Much will be down to local decision-making and, in particular, the individuals now employed in PCTs will be looking to transfer across to local authorities as the size and shape of public health teams materialises over the months ahead. We are not going to prescribe from above in determining how public health teams should be configured in local authorities, but there will be considerable support in the advice and expertise available from the centre.

[Baroness Finlay of Llandaff]

There is much that is welcome within the report but I have some reservations. When the directors of public health are employed by local authorities, will the local authorities also be responsible for their appraisal? Who will be responsible for their revalidation? Will there be audits of the impact of any interventions? Will there be co-ordination of those audits to see which interventions are the most effective? Will there be research in public health to find the most effective ways of guiding people’s behaviour so that they contemplate change? The word “nudge” has been used in the Statement. This goes back to Julian Tudor Hart’s work, many years ago, highlighting the inverse care law. It will be really important that directors of public health do not become isolated in a local authority where they find it difficult to bring about change.

[Earl Howe]

My Lords, the noble Baroness will see when she has a chance to read the relevant section of the White Paper that local directors of public health will be jointly appointed by Public Health England at the centre and by local authorities. We see that as important because they will be fulfilling multiple roles. For example, the health protection role fulfilled by Public Health England will have to be delivered at a local level and, to that extent, it is important that directors of public health are accountable upwards to the centre. At the same time, in much of their work, particularly on health improvement, local directors will be accountable to their local authority and their local population. There is a dual accountability working here.

On appraisal mechanisms, I think it is too soon to say, as we have not worked out the detail of that, but clearly, that will have to reflect the dual accountability I mentioned.

On the audit question, we are issuing a paper about the outcomes framework. The way in which outcomes are assessed and audited will be key to ensuring that the interventions and initiatives that are put in place are evidence-based, that they are relevant and that they have an effect. I hope that the noble Baroness, for one, will feed into that consultation.

Finally, the noble Baroness asked about research. There will be two main engines for public health research. One is the NIHR school for public health research, which will consist of leading academic centres of excellence focusing on evaluation and what works practically and can be applied across the whole country. The other will be the policy research unit on behaviour and health, located in the department, the opening programme of which will initially focus on four behaviours; namely, diet, physical activity, smoking and alcohol consumption. It is very important that we get closer to what motivates people to change behaviour.

Health: Academic Health Partnerships

Baroness Finlay of Llandaff Excerpts

Monday 29th November 2010 Lords Chamber

Tabled By

[Baroness Finlay of Llandaff]

To ask Her Majesty’s Government how they propose to preserve United Kingdom academic health partnerships.

[Baroness Finlay of Llandaff]

My Lords, I declare my interest as a clinician and as a former vice-dean of a medical school. Clinical academics are at the heart of academic health partnerships. Traditionally, clinical academics have mostly been doctors and are the clinical academic leaders of today. But other health professions are joining this group who are employed by universities to research and teach, as well as having direct patient responsibilities. Medical schools are at the heart of this unique position that juxtaposes research abilities within the clinical context, stimulating questions that need answering and permitting studies to be planted in reality.

The UK has a fantastic record in biomedical research. Some 10 per cent of all the academic output in the world is from the UK, but we have less than 1 per cent of the world population. Twelve per cent of listed medical research citations are from the UK, second only to the US, and 19 of the 75 most widely prescribed drugs were discovered here. Investment in biomedical research made over the past 20 years is reaping dividends. The challenge is to get the findings translated into routine practice. Research assessment exercises have tended to steer towards basic science as it is easier for the RAE than applied research. Simultaneously, NHS management has been driven by targets. It is the UK medical schools that sit in the middle of this financial tension. Although tension can be creative, there is a danger that knee-jerk financial responses can undermine long-term, potentially very profitable investment if academic and clinical medicine are forced apart by short-term commissioning decisions.

Countering this pressure has been the National Institute for Health Research, in large part inspired by Dame Sally Davies. Its impact has been phenomenal. Schemes it has supported are being copied and rolled out in the devolved Administrations. Clinical academic training fellowships are attracting increasing numbers of the brightest young doctors as state-of-the-art activities are introduced into trusts, adherence to guidelines improves and evidence-based best practice spreads. The five major health sciences centres in England, Imperial College, King’s College, University College London, Manchester and Cambridge, are direct products of this initiative. They build on the juxtaposition of research and direct clinical care, with major laboratory research linked to clinical practice. But there is also a major benefit to UK plc from all the other academic centres. So I ask the Minister for reassurance that the Department of Health is working closely with the Department for Business, Innovation and Skills to maintain our profitability from clinical academia.

There is good evidence that clinical outcomes are better from all routine clinical services that are research and teaching active. Indeed, that was recognised in the White Paper. Medical schools responsible for the undergraduate teaching of tomorrow’s doctors are all active in research and they have clearly demonstrated that investment pays dividends. For example, every pound of public money invested in cardiovascular research has, after 15 to 20 years, generated a benefit of 39 pence annually in perpetuity. Recent translation of research into practice is illustrated by the reconfiguration of stroke management in London, with better clinical outcomes now that many stroke units have been rationalised down to centres managing hyper-acute stroke providing rapid thrombolysis, decreasing morbidity and long-term care needs.

We take for granted the many previously unimaginable surgical procedures and drug treatments that are now an everyday occurrence. When people are seriously ill they want a specialist to guide their management; someone who is research-active in the area of their disease. I ask the Minister how the importance of academic medicine will be recognised by the GP consortia, many of which will be led by GPs who are not involved in research. How will public health research be supported and financed as public health moves to local authority control?

The health and wealth agenda is served by maintaining the momentum in clinical academia, yet we are already seeing an adverse drift. The pharmaceutical industry is drifting off to other countries with consequent revenue and job loss to the UK. In 2002, 6 per cent of the clinical trials in the world were conducted here but by 2007 this had fallen to 2 per cent.

The recent NHS White Paper speaks strongly of the benefits of research with 10 distinct references to it. It states:

“The Government is committed to the promotion and conduct of research as a core NHS role”.

It goes on to recognise that, particularly in lean financial times, research can provide routes to improve health outcomes and reduce inequalities. Following the consultation on the White Paper, can the Minister reassure us that the commitment to those centres that develop research and unlock synergies between research, education and patient care, remains stronger than ever?

Medical schools have been working with their NHS university hospital partners to plan for the future. They recognise that health and higher education have flourished with political support over recent years and that the global recession’s impact on the UK’s economy will change this growth trajectory. Future success and sustainability require that the core businesses of teaching, research and healthcare delivery are aligned to weather the changes in the financial climate. Collaborative working, not competitive vying for resources, will be the way forward.

Within the NHS the governance system should be based on proportionality of risk rather than “one size fits all”. Clinical research ethics committee processes have speeded up but bureaucratic blocks to research still exist so that opportunities cannot be grasped even though economic recovery will depend on them. Inspection processes, such as the Medicines and Healthcare products Regulatory Agency inspections, can seem excessively laborious. I ask the Minister: what levers are there in the new NHS to address such blocks to innovation and research?

The new GMC document, Tomorrow’s Doctors, requires the doctors of the future to focus on leadership and a lifetime commitment to improvement in recognition of the importance that such a skilled workforce will bring to the wealth of the nation. Training does not end with a medical degree. Postgraduate training takes years and currently it is the responsibility of postgraduate deans, but where will the postgraduate deans sit? They are not mentioned in the White Paper.

Clinical academics emerged during the postgraduate years. The Wellcome Trust postgraduate fellowships aim to recognise and grow the UK’s future medical academics. As specialty and primary care trainees develop an understanding of applied research when working clinically, and as strategic health authorities disappear, it makes sense for universities to be persuaded to house the postgraduate deans, who will not usually be RAE returnable and so will need to have some honorary contract arrangement. However, these deans need a ring-fenced budget to have a lever on foundation trusts to employ this workforce and ensure high-quality training.

Vice-chancellors, too, need to understand the benefits brought from effective partnerships with the NHS and from engaging with the postgraduate training agenda. Structures and performance that match the NHS agenda require incentivisation: for example, by adding locally relevant work with industry to the criteria rewarded by panels assessing the impact of research for the funding councils.

Academic health partnerships can bring solutions to pressing public health issues, both here in the UK and globally. They represent an investment in our foreign policy. They can bring solutions to the requirements of an ageing population susceptible to multiple chronic diseases. Even stronger links between education research and service delivery can optimise the health and wealth of the nation. I look for reassurance that there is an ongoing and, indeed, increasing commitment to this agenda.

Medical Profession (Responsible Officers) Regulations 2010

Baroness Finlay of Llandaff Excerpts

Tuesday 23rd November 2010 Lords Chamber

[Baroness Thornton]

My Lords, as the Minister quite rightly suspects, it was a combination of the report of the Merits of Statutory Instruments Committee on 7 October and my concerns that some aspects of the statutory instrument as drafted need further explanation that caused me to put down this amendment to the Motion this evening. I think it is important to say from the outset that as one of the Ministers who guided the Health and Social Care Act 2008 through your Lordships' House with my noble friend Lord Darzi, I am very pleased that this Government are showing determination to push ahead with this agenda because at the heart of this legislation are patient safety and ensuring that all clinical professionals deliver high quality, effective and safe care to their patients.

I fully appreciate that responsible officers are integral to improving care, and the development of their role seeks to raise the already high standards of the overwhelming majority of professionals, but their job is to identify and swiftly deal with the small number of staff who are not able to meet those standards. The public, professionals and the NHS have a right to be assured that licensed doctors are fit to practice.

I have absolutely no desire to delay the important matter of implementing this legislation. However, I think that it is important that the secondary legislation does the job that the original legislation intended. The report by the Merits Committee raises some important questions in this regard, as do some of the important bodies whose membership will, as it were, be on the receiving end of the instruments.

I think that the regulations do a very good job of describing the duties of the responsible officer and, indeed, the connection between responsible officers and designated bodies and medical practitioners, and this leads me to my first set of questions. Part 1 of the schedule contains a list of designated bodies that includes at least two organisations that the Government intend to abolish: strategic health authorities and primary care trusts. I join the Merits Committee in its recommendation that the House seeks clarification on how the Government's proposed changes to the NHS structure will affect the revalidation scheme in general and these regulations in particular.

Since the 2008 Act, the UK Revalidation Programme Board—hosted by the GMC, which I thank for its briefing and comment on this matter—has been rolling out the reform in phased stages, including a number of pilot exercises which aim to produce a well informed and robust system. Can the Minister tell the House how the changes that have been proposed will affect the pilots and their results? For example, the published guidance says that the responsible officers themselves will be assessed by the responsible officer in the strategic health authority, so what will happen now? How will the Government overcome this problem? I anticipate that we can expect some further orders and, if so, when and will they too be piloted? If nothing exists in the structure of the newly reformed NHS between groups of commissioning doctors at local level and the NHS Board at national level who or what will perform this function?

At the time of the original legislation, we had considerable discussion about the GMC and its role in this matter and about not conflating its particular and important role as the independent regulator for doctors in the UK or, indeed, creating conflicts of interest. At the moment, it seems to me that the only body that would appear to have a structure between the very local GP consortia and the national board is the GMC. What is the Minister’s view of this? How will revalidation work under those circumstances?

I thank the Minister for forwarding to me the letter that his honourable colleague Anne Milton sent to members of the Delegated Legislation Committee in another place. In this letter, she addressed the changes of architecture to the NHS. However, I am afraid that I did not find her explanation very comforting. She says:

“The Government’s proposed changes to the structure of the NHS set out in the White Paper ‘Equity and Excellence: Liberating the NHS’, in particular the abolition of PCTs and SHAs, will not affect the majority of organisations designated under Regulations, including NHS and independent hospitals. These organisations need to start putting the systems in place that support doctors, and provide the information that demonstrates the quality of care they provide. Without this, there is a danger that doctors will be inadequately supported for the introduction of medical revalidation in 2012. I believe that the medical leadership and stability provided by having responsible officers in place will also be important during this period of change”.

Well, quite: the two bodies that can provide that leadership are being abolished.

I turn now to concerns that have been expressed by professional organisations, which particularly led the Merits Committee to say that,

“these regulations are drawn to the special attention of the House on the grounds that they imperfectly achieve the policy objective”.

When I was a Minister, I would have regarded that as the parliamentary equivalent of being put on the naughty step and given a detention at the same time. I think that the Minister needs to give some thought to this matter and to put his responses on the record.

The British Medical Association has said that the laying of the order is “premature”. Although I am not one for delaying these matters, the Minister needs to address its concerns. The Royal College of Surgeons has expressed disappointment that many of its concerns were not addressed in the regulation. It raised the issue of potential conflicts of interest to arise from the installation of responsible officers with simultaneous corporate board responsibilities—for example, medical directors.

The RCS seems to think that such officers might be torn between trust obligations and the professional role of the responsible officer. I am sure that the Minister will be familiar with the examples that these organisations have raised. How do the Government intend to avoid the revalidation recommendations becoming the tools of managers and trust management agendas, rather than matters relating to the compliance of GMC and Royal College standards? Will the Minister confirm that it is the responsible officer’s responsibility to examine the doctor’s clinical ability and professional conduct, not his contribution to the meeting of trust budgets or targets? On this matter the regulations appear to be silent. Perhaps the Minister will expand. The RCS has expressed particular concern about the failure to incorporate whole practice appraisal in these provisions. I think that the Minister needs to give the House an explanation and reassurance about the need for the comprehensive protection to which patients are entitled.

On indemnity, will the Minister confirm how the Government will approach the issue of the potential increase in contributions for medical directors who take on the role of the responsible officer?

Finally, the GMC has expressed concern about appeals and that there is a significant omission of local appeals systems. The GMC fitness to practise processes should not be both the first and the last resort for appeal. There should be a viable appeals structure that flows up to fitness to practise. The British Medical Association says that in some organisations progress has been slow in demonstrating the capability to pull together the necessary data to actualise the new system. It says that appraisal has been patchy and disjointed in many organisations, and that that is quite aside from getting around to supporting any appeals system that may arise. I have raised several issues and I suspect that other noble Lords will seek clarification on the various other issues. I look forward to the Minister’s response.

[Baroness Finlay of Llandaff]

My Lords, we all know the sad history of this, through Shipman, which has led us to where we are today. I do not want to block these reforms because they will improve medicine for patients and for clinicians. But there are some questions which need to be sorted out urgently. One question is the role of the responsible officer in relation to doctors in primary care, particularly with the reorganisation.

In his opening remarks, the Minister spoke about trusts, but I would suggest that hospital practice is very much the easy end of it. The difficulty is where will doctors in primary care sit? How will the responsible officer work in relation to them? Where will academics sit and who will be the responsible officer, because there is sometimes a conflict, as has been pointed out, between academic priorities and the clinical priorities of a trust where that doctor may have an honorary contract? Even more, what about locums? What about the doctors who are constantly moving around? How will they be captured in the system? How will they be adequately and appropriately revalidated? Even with what used to be called 360 degree appraisal—that is, getting opinions from a lot of people—with locums there is a real danger that they will only spot their friends to fill out the forms because they may have had lots of contacts. Those concerns may never be sufficiently in the system to be raised before such a doctor moves on.

There is also a difficulty for those who raise problems. It may be that the doctor who is seen as the sand in the shoe of the trust, the difficult person, is raising real concerns about the way in which management is conducted, which is impeding good patient care. We know that one of the biggest problems is attitude. Often, the biggest problem encountered is not about the ins and outs of technique, because you can retrain on that quite quickly, but is about someone’s attitude. Someone who is whistleblowing, someone who works in the same organisation—I hate to use the term “whistleblowing”, because it is a sad reflection of the NHS as it is today that that term is around—and raises concerns should not in any way potentially be penalised for doing so. We would just go backwards and not forwards if that is the case.

Given that the majority of doctors are doing a really good job and are very flexible and going through changes, the system that comes in must not be too onerous. It must not be just a tick-box exercise. It has to be subtle enough to pick up real issues around performance and attitude. It has to pick up qualitative feedback, so that a bad attitude is detected, including a bad attitude towards patients.

As regards the responsible officer, I am afraid to say that I am sufficiently old-fashioned to think that I would prefer the minimum time after qualification to be a bit longer. It is not until someone has been practising for about 15 years that they really have accrued enough wisdom to be able to take on what will be a very onerous and potentially important role in relation to their colleagues. We need them to have a degree of wisdom. The appeals system is absolutely crucial if this is to work well and fairly. I hope that the Minister will give us a full reply in his response.

We also must be clear that the system will not pick up another Shipman. This is a clinical system and not a criminal justice system, so no one should be fooled into thinking that it will. Dame Janet Smith pointed out two things. First, the most important information about patient safety is doctors watching other doctors. They have to be able to raise concerns easily. Secondly, a good clinical governance system is a system in which questions can be raised at an earlier stage and more readily. So it is the whole system of the NHS with good clinical governance that will make this work. I hope no one thinks that just having responsible officers putting in appraisals will do the job because that will be a wallpapering exercise.

However, my main concern relates to primary care and to financial conflicts. In a privately managed organisation there may well be a conflict between what is actually in the patient’s best interest and what is being put forward as the protocol in that managed care programme. It may well be that the doctor is working in the patient’s best interests, but not in those of the organisation. Again, there has to be a degree of neutrality among the responsible officers. I hope that the Minister will be able to give replies to all these concerns, and like other noble Lords, I look forward to his response.

--- Later in debate ---

With those reassurances, I believe that I have covered all the questions raised by noble Lords. I therefore commend the draft regulations to the House.

[Baroness Finlay of Llandaff]

Will the Minister clarify that the way in which the regulations are written is sufficiently flexible to allow a doctor to take a career break, to move into a different area or to take a break from clinical practice as it currently stands? Are they also sufficiently flexible to allow the responsible officer role not to be tied to the medical director of a trust, but if the medical director of a trust resigns from that post but is very suitable to remain the responsible officer, they can remain the responsible officer and the medical director can be someone else? Furthermore, are they sufficiently flexible to allow you to be able to get rid of a responsible officer if it turns out that they are not being wise enough?

Although this is slightly irregular, I should point out for clarification that I am not against these regulations at all—I think that they need to go through. My concern about five years is that most doctors are still in training at that stage.

[Earl Howe]

My Lords, the answer to the first question of the noble Baroness, about career breaks and so on, is yes, the regulations allow for that. In answer to her second question, we are not specifying that responsible officers have to be medical directors. As she knows, we are leaving it up to the organisations to decide that. Therefore, she can be reassured on her other questions.

Healthcare: Costs

Baroness Finlay of Llandaff Excerpts

Monday 15th November 2010 Lords Chamber

[Earl Howe]

My Lords, I know that this is a question to which the noble Lord and other noble Lords regularly return, and it has a superficial attraction. The problem with it, I am advised, is that patients who are informed of the cost of their treatment—some patients, at any rate—take that as a deterrent to accepting the treatment in the first place. That is something we need to avoid. Nevertheless, there is an underlying point here; there is a need to provide better information to patients about their treatment so that they can take ownership of their state of health.

[Baroness Finlay of Llandaff]

My Lords, what consideration are the Government giving to seven-day working in the NHS, including renegotiating Agenda for Change, to make better use of the NHS’s equipment, promote early diagnosis and decrease morbidity from complications of treatment that is not overseen by senior staff—particularly over weekends and bank holidays?

[Earl Howe]

My Lords, creating a seven-day service is a particular concern of mine, and the noble Baroness is quite right to raise it, particularly given her long experience in the health service. As for Agenda for Change, any alterations to existing terms and conditions, such as the unsocial hours payment or sick pay, would need to be negotiated in partnership with NHS Employers and trade unions, through the NHS Staff Council.

Health: Chronic Fatigue Syndrome

Baroness Finlay of Llandaff Excerpts

Monday 8th November 2010 Lords Chamber

[Earl Howe]

My noble friend is right to say that there is no diagnostic test for CFS/ME other than a process of elimination and watching the symptoms. It is largely on a self-reporting basis that the blood transfusion authorities will be alerted to the condition unless, of course, a patient’s GP is involved and can report his or her opinion.

[Baroness Finlay of Llandaff]

My Lords, do the Government intend to ask NICE to evaluate pathogen inactivation, which is already used on fresh frozen plasma for children, for blood components as well because of new and emerging infections and the increased risk of infections in donors because of the increase in international travel?

[Earl Howe]

My Lords, I understand why the noble Baroness asked that question. I believe that platelets cannot be stored in refrigerated conditions and are therefore, in theory, open to more infection. I am advised that SaBTO, the expert committee, looked at this and advised that no action was currently necessary.

Healthcare

Baroness Finlay of Llandaff Excerpts

Thursday 28th October 2010 Lords Chamber

[Baroness Finlay of Llandaff]

My Lords, I am grateful to you for allowing me to speak briefly in the gap.

Since 1948, GPs have been independent contractors. GP practices belong to the partners, who increasingly employ salaried GPs rather than taking on new partners. In the consortium, they will need to employ advisers to manage their commissioning responsibility. Therefore, if the constituent practices are offered a good deal by a private company that also, for a fee, manages the commissioning, why not agree? That private company will then effectively own the consortium, do the managed care commissioning and keep the profits for its shareholders—effectively giving control of the NHS funds to private firms, many of which may be based abroad. Will patient need or commercial profit then determine healthcare contracts with local specialists? We live a seven-day society. Without a proper, patient-centred, 24/7 service, patients’ needs will not be properly met. I suggest that GP consortia and employment terms need a radical rethink.