Human Fertilisation and Embryology Authority/Human Tissue Authority
Lord Alderdice Excerpts(13 years, 3 months ago)
Grand CommitteeRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Lord Alderdice
My Lords, we are all grateful to the noble Baroness for achieving this short debate—and it is short; one has only a few minutes. For that reason, my noble friend Lord Willis of Knaresborough will address the HFEA, my noble friend Lady Williams of Crosby will have an overall look at the issue and I will focus my attention on the Human Tissue Authority. I declare an interest, because my wife is a consultant histopathologist in the NHS in Northern Ireland. She does not do any forensic or coroner’s work, but I declare the interest in any case.
The assumption in the noble Baroness’s Question is that these bodies—I will refer now only to the Human Tissue Authority—have increased public confidence and patient safety. I am not at all sure that that is in fact the case with the HTA. When I was much younger in medicine, I remember that one government requirement was that 10 per cent of deaths that did not require a coroner’s case PM would be post-mortemed. Why? Because the final judgment about whether or not clinical judgment was correct comes in the court of the full and rigorous autopsy of the pathologist. There is no other way of being certain. Even then, one may not get a final answer.
What has happened over the last few years is that we have achieved not the 10 per cent figure but the almost complete disappearance of such post-mortems. Many histopathologists, especially those who are newly qualified, will no longer carry out post-mortems. The Royal College of Pathologists is looking at whether it should allow pathologists to qualify without having proper experience in post-mortems, because so few of them are being done. One cannot talk about increased public confidence in post-mortems if the outcome has been that almost nobody wants permission for them to be done. That expresses a lack of confidence in post-mortems, not increasing confidence.
I will be more specific. In February of last year, the president of the Royal College of Pathologists wrote to the then Secretary of State, the right honourable Andy Burnham MP, with an eight-page letter—for obvious reasons, I cannot quote it in any detail—expressing the Royal College of Pathologists’ deep lack of confidence in the work of the HTA. He began the letter by saying that the fall-out of the HTA’s actions risked destabilising the provision of post-mortem examination services in England and Wales. He wrote about the concerns not only of the royal college but of the coroners’ service. He talked about the lack of efficiency, citing the work of the CPA, which undertakes external quality assessments for full laboratory services—in other words, histopathology, haematology, microbiology and clinical chemistry. The fee that the CPA requires for inspecting the entire laboratory service is half that which the HTA requires for inspecting just the mortuary. Even in terms of efficiency, therefore, there are serious questions. When the HTA was established, it had a lot of experienced people who had conducted post-mortems, but that is no longer the case.
If the new Government understand that this is the relationship that has developed between the professional bodies—to the point where pathologists are no longer eager to carry out post-mortems—they would not be responsible if they did not take this issue seriously. Should the Government not ask whether the HTA is the best vehicle to carry out what are undoubted requirements for proper procedures to scrutinise this professional work?
NHS: Targets
Lord Alderdice Excerpts(13 years, 5 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Earl Howe
My Lords, I do not accept that. The previous Government recognised that contestability in the provision of care was a very powerful driver to improve quality of services. I do not think that privatisation of the health service will result from the proposals. We will reach a better stage of quality in provision of care only if we allow the best providers out there to compete for services. As long as the principles of the NHS remain—which they will do under this Government—for a service free at the point of need without being based on ability to pay, we will have the NHS that we all know and love.
Lord Alderdice
My Lords, given that the Government have committed themselves to clinical outcomes and measurable improvements in patient well-being, how will the Government ensure that managerial demands for the kind of target culture that we experienced previously will not overwhelm any attempts to measure clinical outcome or patient well-being?
NHS: Reorganisation
Lord Alderdice Excerpts(13 years, 5 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Lord Alderdice
My Lords, the noble Lord, Lord Touhig, in his introduction to the debate talked about a sense of passion for the National Health Service—a passion which I think all of us in this Chamber share. However, it is not the only emotion that is connected with healthcare. One thing that struck me when President Obama embarked on his programme to improve the quality and breadth of healthcare in the United States was the profound emotional reaction against it. I was astonished, when talking to friends and colleagues who are genuine people, to find that they were frightened that any change would lead to disadvantage, when manifestly for many people in the United States such change would open up new possibilities of healthcare.
I think there is a danger that a similar thing could happen to us, and I certainly understand why. It is not just that people are generally frightened when healthcare is touched but in a time of austerity—something we are all very clear about—there is a fear that any change will be primarily financially driven, the purpose being to cut the amount of money going into healthcare. Even when the Government say something different, it is not really believed. That is a sad legacy of how things have been for a time. It is particularly unfortunate because the previous Government increased the resource available. For a long time, we said to ourselves and to each other, “We’re not spending as much per capita as other European countries”, and the previous Government tried to increase it, with considerable success. But it did not lead in all areas in the health service to a better sense of morale that things were improving. On the contrary, many general practitioners and hospital consultants, who are now paid more and do not have to produce more, have a lower sense of morale and a lower sense of empowerment in running the service. They have felt that their concerns as clinicians—this is not just true of doctors, but is true of social workers, psychologists and all sorts of other professions within healthcare—and decisions about the health service have moved away from them towards what I call managerialism. I have had that expressed to me, which is why I am not at all surprised by the BMA’s approach that any new approach to the health service inevitably means fewer resources available—contrary to historic evidence—and moving away from decisions by clinicians to decisions by managers.
When management was introduced increasingly to the health service it was not a bad thing in itself. It was necessary. The world was becoming more complex but there were seeds of difficulty within it. It became apparent, for example, that when nurses, social workers and others were going to be promoted, they were always promoted out of clinical work and they lost touch with what was happening clinically. Doctors tended not to be, at least in the early days, but their priority was always attending to their clinical work and they found that they did not—or would not—attend meetings; they got more and more frustrated and deskilled, and removed themselves from management. Increasingly, management became managerialism so that the driver was not to ensure that the outcomes of the service were clinical and patient-driven outcomes but, rather, management driven.
We want to see increased numbers of things. For example, when the problem of cancer care was addressed, GPs were told that they could flag up cases that should take priority over any other case. What did that mean? GPs quickly discovered that if they stuck a red flag on a case it would get attention above all the rest, which perversely meant that many of the real risk cases in the pathologist’s waiting list did not get attention, whereas the red flagged one did, not necessarily because it was more important but because there was a perverse incentive to the general practitioner to mark it up in that way. That is what I mean by managerialism as distinct from management, which is necessary and essential.
It is also important to understand that when we look at the need for diversity the phrase “postcode lottery” is used. That can happen but there have to be differences in services. In my professional background of psychiatry everyone knows that there is an urban drift. People with chronic psychotic illnesses, alcoholism, and so on, drift to the centres of large cities, so the kind of service you need to provide is different in a city than in a rural area. To say that it is different does not mean it is worse; it may mean that it is more appropriate. But it means that local people—not just clinicians, but local representatives, patient groups and others with a real concern, and, importantly, those involved in social services—need to be involved in the construction of the services that are available.
In looking at the proposals that are coming out, I started from a position where I was becoming increasingly depressed about whether the health service could ever be fixed. When I retired as a doctor earlier this year I felt extremely depressed about the health service. I genuinely think that there is a chance for things to be better if we can ensure that the resources are sustained, which is an important question at this difficult time. We must ensure that all clinicians—not just doctors or GPs—are involved in the commissioning process and that local people, including elected representatives, patients and those who run other third-sector services are involved in that commissioning process, and can hold those principally involved to account. If that can help us to move to greater integration of health and social care, which is already provided by local authorities and is key in so many of our services for the elderly, as well as maternity and psychiatric services, we can put aside our fear that we are moving to some kind of American system—which we are not, and frankly do not want to see—or a completely commercial service. That is the direction we have been moving towards under previous Governments for quite some time, and it is not the direction of travel that we want.
We need to release the creativity and sense of empowerment of those involved in the service, particularly clinicians of all kinds, along with a sense for patients and others that their concerns matter and their ideas can be transformational. Those at the centre should be prepared not just to let go and give them encouragement but to provide the resources and support to make a health service fit for all of us in a variegated pattern that is appropriate across our country.
Hospices and Palliative Care Services
Lord Alderdice Excerpts(13 years, 5 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Lord Alderdice
My Lords, I thank my noble friend Lord Bridgeman for not only securing the debate but for introducing it with his usual elegance and eloquence. I identify myself both with his comments and those of the noble Lord, Lord Faulkner of Worcester, in praising the importance of the hospice movement and its work, the significance and value of voluntarism, and the need for public, financial and other resource support.
In the short time available to me I wish to address one specific issue—the need for thoughtful and real support for the staff who work on the front line in the hospices. Some years ago I became aware of this issue when I was doing a consultancy for the Belfast Hospice. It became apparent to me that there is a specific kind of emotional strain and stress on those who work in the hospice movement on the front line with the patients. With all other forms of care, there is a variegation of patients and the acuteness of their problems. However, in a hospice, when a patient comes in everyone knows that this is moving towards the end and there is an intensity about the emotional involvement that is quite unique.
In addition, the situation moves inevitably to a form of bereavement. Even if the patient moves out of the hospice and comes back in, it is inevitably moving in that direction. As human beings we are created in such a way that we can deal with bereavement and emotional intensity, but what I saw with some of the hospice workers who were working on the front line with patients was a psychological equivalent of march fractures. All the time there was the development of a close emotional bond and then the experience of bereavement—and then straight into the same situation again and again and again. Many of those who experienced this time after time themselves became subject to emotional trauma—sometimes they fell physically ill—after a number of years.
If these workers were able to move out into another aspect of hospice care—education, administration or teaching—or to move into the NHS and bring with them their experience of palliative care, pain relief and dealing with cancer and other terminal illnesses, they would be freed of that emotional involvement and make a tremendous contribution. The burden of my request to my noble friend is that the NHS will engage with the hospice movement to provide opportunities for support and constructive engagement that values the experience of those involved in the hospice movement but ensures that they do not find themselves suffering because of the enormous emotional commitment they made to this peculiarly special and costly form of caring.
Health: Passive Smoking
Lord Alderdice Excerpts(13 years, 5 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Lord Glentoran
My Lords, the noble Lord will know that there is a considerable—
Lord Strathclyde
Let us hear from a Cross-Bencher first and then from my noble friend Lord Glentoran.
Lord Alderdice
My Lords, on Her Majesty’s Government’s commitment after ratification in 2004 to produce a five-year implementation report, I note that the WHO website gives no indication that the report due on 16 March this year was in fact forwarded to the WHO. Will my noble friend confirm whether the report has been forwarded?
In addition, given the enormous amount of smuggled tobacco—accounting for some half of hand-rolled tobacco and 10 per cent of cigarette tobacco in the United Kingdom—what has happened to our commitment under Article 15 to deal with illicit tobacco and, indeed, to the protocol mentioned in the commitment in the Uruguay meeting of earlier this month to ensure that, by 2012, others will also fulfil their responsibilities?
Earl Howe
In answer to my noble friend’s first question, yes, the report has been forwarded to the WHO.
On illicit trade, HMRC leads on tackling the availability of illicit tobacco and has carried out—as I am sure my noble friend knows—a great deal of activity to tackle that market through its overseas network of fiscal crime liaison officers, as well as through activity at the border and inland detection work. HMRC also works closely with local authority trading standards officers. Those efforts have led to a decline in the market share of illicit cigarettes from 21 per cent in 2000 to 11 per cent, according to the latest available figures. However, he is right that hand-rolling tobacco in particular remains a problem.
Public Health
Lord Alderdice Excerpts(13 years, 5 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Lord Alderdice
My Lords, no one who has listened to and observed noble Lords on the Front and other Benches opposite would think other than that they are passionately committed to the health service and to the health of the nation. However, as they look back over the past 13 years, they would also observe that at the end of that time issues such as obesity, smoking, sexually transmitted diseases, mental health and the increasing disparity in morbidity between people who live in poor areas and better-off areas were uncompleted in terms of what they wanted to see. It therefore does not seem unreasonable to ask whether that was partly because the approach had reached the limits of its validity.
That is why, in welcoming the Statement, I ask my noble friend to address two brief questions. First, as we move towards more local responsibility for provision of public health, and the undertaking of that responsibility by local directors of health and local health and well-being committees, is there a recognition that that transition cannot happen without real input and help from Public Health England and from those experienced in delivering public health? It cannot be adopted at the drop of a hat. Secondly, when it is adopted—and different approaches will be taken in different areas, quite properly and, in many ways, more effectively—is there a recognition that Public Health England will also have a role in liaising with and providing a network among the directors of public health and health and well-being committees so that they can promote health in the way that we all want?
Baroness Northover
I remind noble Lords that we have a very short amount of time and that they should be extremely brief, either with a question or with a comment. They can do either but they should be as brief as possible. I shall try to be as fair as possible in getting around the House.
Health: Academic Health Partnerships
Lord Alderdice Excerpts(13 years, 5 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Lord Alderdice
My Lords, I too want to express my appreciation to the noble Lady, Baroness Finlay of Llandaff, for obtaining this debate. As the terms of the motion are reasonably wide in referring to academic health partnerships, there are a number of elements that I would like to address briefly in the few minutes that are available to us.
When one thinks about academia, it seems to me that one should think not just of research but of the teaching of undergraduates that helps them to develop, of training—the clinical dimension of the work has to continue even in the postgraduate period—and, of course, of research. However, over the past 30 or so years, quite substantial changes have taken place in our approach to academic health partnerships. If one goes back 30 or 40 years, a great deal of academic work focused on medical practitioners who had a particular interest in and aptitude for this kind of work. Such practitioners spent part of their time employed by the National Health Service, largely, but they also did academic work, often with honorary contracts with universities.
Two or three major changes have occurred since then. One is that, as health trusts of various kinds—primary care trusts, hospital trusts, community trusts and so on—were set up and became increasingly business orientated and managerial in their approach, each trust looked at how far research was helpful to its own business plan. If the research was not directly productive, there was a disincentive to doctors to focus on research. As time has gone on, that has become an ever greater problem because doing research has itself become more difficult. There are many more ethical hoops—quite understandable in many cases, though not all—and funding has become more difficult. Junior medical staff, who might have been more than delighted to participate in research 20 or 30 years ago because it helped their curriculum vitae, now find that such research does not benefit them too much and it is much more difficult for them to find time for it. Research has become a much more difficult exercise with the increasing managerial approach in the NHS.
Universities, too, have had to look at whether or not they could be collaborative in that rather relaxed, laissez-faire way. Universities have demanded clinicians who focus very heavily on research and do well in the RAE, while NHS physicians have increasingly focused on their NHS clinical work. In addition, of course, there is now a much wider body of healthcare professionals involved in all these activities. The focus is not just on doctors but on the whole range of healthcare professionals—and quite rightly so—and that means that the picture has changed very dramatically. Meanwhile, the amount of resource available for research has not increased in a commensurate way. That is also true for teaching. Therefore, it has sometimes been the case that there has been a widening without necessarily a deepening of the quality of teaching and training.
It is not as though the new Government are coming to a situation in which everything has been perfect. In the past few years, there was a recognition of some of those issues by the previous Government. Following the Darzi report, the Government promoted some important centres of excellence, which have already been referred to in the debate and which are to be commended and supported. One of the concerns of the noble Lady is that the Government’s proposals should take away nothing from the progress that has been made. I very much hope that my noble friend will be able to reassure us on that, because the White Paper makes clear that,
“The department will continue to promote the role of Biomedical Research Centres and Units, Academic Health Science Centres”—
which were, of course, what came out of the Darzi report,
“and Collaborations for Leadership in Applied Health Research and Care, to develop research”.
At this stage, where change and development is being proposed, one wants to be reassured that those centres of excellence will indeed be built upon. There is, in fact, a tribute earlier in the White Paper to the importance of the work of the noble Lord, Lord Darzi. I also note that specific emphasis is given to the NHS commissioning board taking some responsibility for promoting involvement in research and the use of research evidence.
However, although it is extremely important to ensure that the relatively small number of high-quality centres of excellence is maintained, sustained and developed, that is not enough. There must be some way in which we can begin to rekindle the interest of young doctors, nurses, psychologists, social workers and the panoply of health professionals to realise that research is an important component in their own professional development and that, if they are to understand the implications of research papers, they must have at least a little experience of research early on. Therefore, I seek some reassurance from my noble friend that, as we move forward into potentially exciting opportunities for a newly configured health service, we will try to regain some of the creative excitement about research and academic work of all kinds that I think has been somewhat lost in the overly managerial and overbureaucratic approach that has been applied not only to healthcare but, at times, within some of our leading academic institutions.
Medical Profession (Responsible Officers) Regulations 2010
Lord Alderdice Excerpts(13 years, 5 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Lord Patel
My Lords, I concur with the comments of my noble friend Lord Walton of Detchant. It is important that we allow these regulations to pass. As he has said, the issue of revalidation has been smouldering away, to use his words, for many years. I recall from when I served on the GMC over eight years ago that the revalidation issue predates Shipman and has nothing to do with that issue. As my noble friend has said, this is a process and it is important that the regulations should be passed because we need the responsible officers to be appointed pretty soon so that the GMC can train them up and identify any issues before the process of revalidation begins. I understand that all the devolved Administrations have agreed that it should start by autumn 2012. If that deadline is to be met, we need the responsible officers long before that.
My conversations with officers of the GMC suggest that the council is well aware of the concerns raised. They know that when the legislation to reform the NHS is brought forward, the issue of what happens in primary care with doctors working as commissioners, and how they are to be revalidated, will have to be addressed. They are confident that they will be able to do so.
As for the other professional organisations that have also commented and to which the noble Baroness referred, it is interesting that only one has raised concerns; the others have not. All the other royal colleges have been involved in working with the GMC to identify how revalidation will be carried out in their own specialties and they are satisfied with the mechanisms that will be used. They are also satisfied that the pilots that are now being carried out will identify the issues.
It is important that we now approve these regulations and allow the responsible officers to be appointed. We will have other opportunities to debate the matter again during the next stages.
Lord Alderdice
My Lords, it is always difficult when new Governments come into place and want to make important and sometimes radical changes to structures and arrangements while, at the same time, valuing some of the work that had been begun but not completed by a previous Government. As other noble Lords have said, the previous Government, and perhaps even an earlier one, moved towards revalidating doctors. This is a very complicated and difficult issue, but the Government moved in that direction; timetables were set but became a little delayed. However, if the Secretary of State in this new Government were to take the advice that has been proffered—that until PCTs and strategic health authorities are set aside and the new arrangements are in place we should not move to the appointment of responsible officers—we would be looking at 2014 or 2015, or after the next general election, before we could move forward. It is understandable that people should quite reasonably say that there is a dilemma here, but we must try to keep up the momentum, which is the point that the GMC has made.
It is perfectly correct that a number of matters are not yet clear and resolved. Some affect me, and I shall advert to them in a moment. The proposals for the reform of the NHS have not worked through the process—they have been announced but are not yet through Parliament—and it is not only possible but almost certain that there will be significant changes and developments. I hope my noble friend will be able to clarify some of the issues, but it would be expecting rather a lot for him not only to clarify how matters stand at the moment but to predict how they might stand further down the line when some things may have changed.
In the present situation, in most cases but not all, appraisal processes are already going on. Up until earlier this year, every year I produced a huge lever arch file containing details of all the things that I had been through. So the process is already in place and it is the responsibility of medical directors in trusts to make sure that it is in place. However, they cannot possibly carry it through themselves because so many need to be appraised. They therefore have to devolve the responsibility for the detail and the face-to-face work to someone else. Exactly the same thing will happen to the responsible officer.
Are there potential conflicts of interests? There already are because those who are responsible for the appraisals are also responsible for clinical merit awards of various kinds, for the recognition of a person’s work and for the creation or demolition of their clinics. All these conflicts are already there. That is not to set them aside and say they are unimportant—they are very important and very difficult—but we are facing something that is not in itself radically new but a problem with which we have been struggling for quite some time. Further orders may well come subsequent to this that will help to take the matter forward, but that does not mean that we should delay the current regulations.
Let me put to my noble friend a dilemma of my own on which he may or may not be able to help. What will happen to those who do not necessarily operate all the time only in the NHS in England, Scotland and Wales? I note that Northern Ireland is not included in this and, of course, the movement backward and forward between this part of the world and the Republic of Ireland is substantial. What happens if a doctor qualifies and works here for a while, then goes to work for three or four years in the Republic of Ireland and then comes back to work in the United Kingdom but the process of validation has not operated in quite the same way? Of course, we have free movement not only in these islands but throughout the European Union. What happens to those who have operated outside the UK? These are real dilemmas that have to be dealt with.
We have often heard it said that it is better to start, pilot and work your way through than to produce something that has not been tested out but is a fiat—a fait accompli. My noble colleagues on the Cross-Benches have expressed reasonable concerns and a determination to keep up the momentum for revalidation. In supporting these regulations, that is also very much my mindset, and I hope to see further developments over the next year or two.
Lord Rea
My Lords, I simply report that the two professional organisations to which I belong, the Royal College of General Practitioners and the BMA, basically support the regulations. That is in spite of some doubts about the timing and some of the other points that noble Lords have raised today. It is good that responsible officers will be appointed before the detailed work of setting up the revalidation process is completed. They will play an important formative role before later acting as scrutineers or umpires—I hope not inquisitors—in the revalidation process. I shall be interested to hear the Minister’s response to the cogent questions that my noble friend and almost all other noble Lords have raised.
NHS: Prebiotics
Lord Alderdice Excerpts(13 years, 6 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Earl Howe
The noble Baroness is absolutely right, not for the first time, about the devastating incidence of C. difficile infection. More than 25,000 cases of C. difficile infection are reported annually and there remain significant variations in outcomes among organisations.
In principle, prebiotics should be beneficial, but there is in fact little good evidence to show that they work or that food can provide a prebiotic effect. There is likely to be considerable inter-patient variation in the gut flora response to prebiotics, which could be exacerbated by differences in diet. However, as I have already indicated, we will look closely at the issue.
Lord Alderdice
My Lords, given the difficulties and dangers of Clostridium difficile, can my noble friend reassure me that the Department of Health has noted that the Food and Drug Administration has in recent days approved fast-track designation for a parenteral toxoid vaccine, which thus opens the possibility—I hope—that immunisation will be possible, in particular for elderly, vulnerable people who are in danger of developing Clostridium difficile infection?
Earl Howe
My Lords, I am aware of the interesting development of a vaccine for C. difficile, but I understand that the vaccine is still in clinical trials. As my noble friend indicated, the company may be seeking agreement from the US FDA to fast-track the application when the development programme is complete, as that would give them access to the US market. It is of course for the manufacturer to decide when and if it wishes to seek access to the market in the UK and the wider EU.
Healthcare: Costs
Lord Alderdice Excerpts(13 years, 6 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
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.
Lord Alderdice
My Lords, I know it is extremely difficult, but has my noble friend had the opportunity to explore how much of the increase in health service costs in recent years has come about because of the increase in administration and management costs? I refer not simply to the salaries of administrators and managers but to the administration for the administrators, and to the amount of time that clinical and professional staff must spend in servicing the requirements put on them by administrators and management.
Earl Howe
My noble friend is right to pinpoint this area. If my memory serves me correctly, the average annual increase in management and administration costs over the past 10 years has been 6.2 per cent per year, which is by far and away higher than the increase in costs in clinical areas, for example. That is why we are determined to reduce the administrative cost of running the NHS, and we are in the process of planning for exactly that.