Health: Diet

Lord Alderdice Excerpts

Tuesday 13th July 2010 Lords Chamber

[Earl Howe]

My Lords, as I said in answer to the noble Lord, Lord Krebs, we fully recognise the important role that the FSA plays. I identify myself fully with his remarks about the reasons why the FSA was created. I speak as a former junior Minister in the department that he led in such a distinguished way, and I realise fully the force of what he said.

[Lord Alderdice]

My Lords, given that the Government, directly and indirectly, are one of the largest employers in the country, and therefore the provider, directly or indirectly, of lunch and other meals, is there anything they can do to ensure that the meals provided and the diet available to employees, direct or indirect, of the Government are improved in line with what the noble Lord asked?

[Earl Howe]

My Lords, there is, and I am grateful to my noble friend. He will know that the healthier food mark initiative is one thing that the Government can do to enable the public sector to lead by example, in schools, hospitals and care homes. The healthier food mark has been developed over the past two years as a benchmark to raise the level of nutrition and sustainability of food served in the public sector. It sets clear guidelines on healthier and more sustainable food and recognises achievement, so I hope that it will lead the way.

NHS: Pain Management Services

Lord Alderdice Excerpts

Wednesday 7th July 2010 Lords Chamber

[Lord Alderdice]

My Lords, the noble Lord, Lord Luce, who introduced the debate, and an astonishing number of other noble Lords have described how their own personal experiences have given them a profound insight into the importance of the dread subject of chronic serious pain. They have also shown an understanding and deep appreciation of the possibilities of treatment of this disorder.

In the short time available to me, I wish to stress three points. The first is the biopsychosocial aspect of pain. I hope that my noble friend will help the department to understand, as the noble Lord, Lord Walton of Detchant, pointed out—so clearly as he always does—the hugely important physical and biological aspect of much pain, and as other noble Lords have pointed out, its psychological aspects, particularly the noble Baroness, Lady Masham of Ilton. Others have pointed out the social aspects, as did the noble Baroness, Lady Morris of Bolton. Pain of this kind is sometimes largely physical in its origins, but, at other times, the psychological and the social components play a very important role as well. They do so not only in its origin but also in its treatment and management. All those elements are extremely important. There is a tendency sometimes to think that the biological side of things is only about pain relief in the form of medication. There are other kinds of physical approach to the treatment of pain. My first point then is the need to understand the biopsychosocial nature of the disorder and its treatment.

My second point is the need to pay attention to the needs and wishes of the patient, as the noble Baroness, Lady Pitkeathley, pointed out. In principle, at least, that is not so difficult when the patient’s cognitive function is intact and they are able to communicate. Many patients suffer from pain, but their cognitive function is impaired and they may be suffering from dementia. Many elderly people suffering from dementia do not have their pain understood and attended to because they are not able to communicate it clearly. That is also true at the other end of the age scale. Many children are unable to communicate their pain clearly because they cannot even understand what is happening to them. Their pain is not properly dealt with and their misbehaviour is sometimes treated inappropriately. Likewise, the pain of those with psychiatric disorders is sometimes simply dismissed—“Oh, it is all in their head”—and is not properly dealt with. Those with learning disabilities also have great difficulty in communicating the nature of their pain. As the noble Baroness said, attending to the needs and wishes of the patient is crucial, but it is not always easy, and I trust that my noble friend the Minister will be able to assure us that it is appreciated that attending to the needs and wishes of patients is more complex than simply listening to them.

My third point is that, although it is extremely important to have expert pain clinics, only a minority of patients will ever be able to get to them. What can be very helpful to doctors, nurses and other clinicians who deal with patients with pain is to be able to contact such clinics and ask over the telephone directly for advice on how they might handle them. We shall never be able to train all our practitioners, GPs, community nurses and so on in the most up-to-date and complex ways of dealing with these patients, but we can make sure that they have access to those who are up to date. When I was a psychiatrist, it was possible to contact other clinicians who understood how to deal with such things and to receive advice from them and then make it available to my patients. I trust that my noble friend will be able to reassure us that practitioners will be able and encouraged to make such contact, and that it will be seen not as a failure of their professional ability but as a fulfilment of it if they do so.

Health: Primary and Community Care

Lord Alderdice Excerpts

Thursday 24th June 2010 Lords Chamber

[Lord Alderdice]

My Lords, like other noble Lords, I commend the noble Lord, Lord Mawson, on obtaining this debate, particularly in this area of healthcare—the bringing together of primary and community care and learning practical lessons from the work that has been done.

Until my retirement from psychiatry and the NHS at the end of March this year, I had worked for many years in healthcare in Northern Ireland. As some noble Lords will know, we have had a fully integrated health and social care system since the early 1970s. This has been enormously beneficial. Let me give noble Lords some idea of what it means. When I was working as a psychiatrist, a patient would be referred to me by a general practitioner in the same trust. I would see the patient as an out-patient, and I would have at the clinic, as part of the multidisciplinary team, nurses, social workers, psychologists, as well as junior medical colleagues. Indeed, secretarial and administrative staff were very much regarded as part of the team because they would meet the patients. How the staff related to patients on the telephone or in reception was an important part of managing them. If they needed to be admitted to hospital, the same team would be able to work with those involved in patient care and the patients. All these teams included social care. Social services staff were as fully involved in the trust as the medical or other professional clinical staff.

With regard to the management of the trust, a manager of doctors might have been a doctor but they might also well have been a social worker, an experienced nurse or some other professional within healthcare. It meant that people were able to work together right across the disciplines with the single concern of ensuring the best possible health and social care for patients, whether they were at home or a daycare facility or whether they were short or long-stay in-patients.

My noble friend need not be concerned; I am not proposing that there should be structural changes in the healthcare system in England, but that structure facilitated us in working as multidisciplinary teams. However, we discovered that there was a limit to multidisciplinary teams, because after a time it became apparent that there still had to be an element of leadership. It was not enough to get the professionals to work together as though everyone had the same role and the same responsibilities; it became apparent that there was a need for leadership. Whether that came from the medical side or from social work, psychology or nursing was much less important than the skills that the individual had as a leader. Being a leader is not a particularly professional qualification; it is a personal one.

I say to the noble Lord, Lord Mawson, that for many of us a medical model is biopsychosocial. The notion that it is only about the physical and does not include the mental, emotional and relational is, from my point of view, a rather perverse idea of what medicine is really about. However, I accept that there has been a tendency for doctors and others outside medicine to push medicine in that direction, and it is down to those of us who believe in something different to open up the windows and to help people to understand that we are talking about not just the whole person but the whole person in their relationships with others. That is all part of good medical work.

We did not just find a limit to the notion of multidisciplinary teams; we also found a very definite limit to the notion of managerialism. Of course, as things became more complex and finance became involved, it became necessary to have managers and administrators. At the start of the process, they were seen as serving the requirements of professionals and patients. However, it was not long before they began to regard themselves as the bosses of the clinicians—and indeed sometimes of the patients as well. They would be far less concerned about the professional and clinical requirements or the requirements of the patients than about balancing the books or having a growing managerial empire. Every time there was a reorganisation and restructuring, the one group that never seemed to reduce in number was the managers. There always seemed to be places for them to go and none of them ever seemed to be made redundant in restructurings.

The truth is that an arrogance began to develop whereby the people at the centre, whether they were managers or in Whitehall, felt that somehow they had more real interest in, concern about, knowledge of and expertise in what was good for patients and patient care than the people who had committed themselves to that work from the beginning of their professional lives. Some of the managers came from business and had no real understanding of the complexity of healthcare. However, they were encouraged by Governments who saw a market model as being the way to run a healthcare system. That never seemed to make much sense to me because, if the bottom line was important for you, the best thing you could do was to let many of the patients die as quickly as possible so that they would not be a charge on the state.

The market principle just does not work when you apply it to healthcare. In fact, if you apply it too energetically, you provide perverse financial incentives to do absolutely the wrong things. I do not mean that there is no place for the market but I have always felt that a menu was better than a market—yes, there is choice, you make decisions and you understand that different approaches involve different costs; nevertheless, there is some kind of informed choice that is based not just on the cost but on the value of what you are trying to obtain for yourself or your patients.

Therefore, there is a limit to multidisciplinary teams that have no leadership; there is a limit to the notion of managerialism as the way to run a healthcare system; and there is a limit to the market as a model for running a healthcare system. Those are some of the things that we have learnt in healthcare over the past 10 or more years.

However, there are also a couple of major challenges that we need to address, one of which is the enormous change in the social patterns of the lives of the people with whom we are working. The noble Lord, Lord Rea, mentioned that we have an older population, and that brings with it increased challenges of all sorts—ethical and management problems and clinical difficulties. For example, certainly for a period of time, we were largely successful in getting rid of infectious diseases, and that let people live longer, so they lived longer in order to develop cardiovascular disorders. When you dealt with those, they then lived long enough to develop cancers of all kinds and, when you dealt with those, they then lived long enough to develop dementia. It is not as though when you deal with a whole set of problems they all go away. We live longer and experience other kinds of problems.

That does not mean that we give up but we have to be realistic that all sorts of changes need to be addressed. There are changes in social patterns, including the size of families, the type of family units and a range of people from all parts of the world with all sorts of different dietary backgrounds and physical backgrounds, infectious disorders, and so on. We have to deal with all those things. We have to be alert and aware of change, which is quite a challenge. As such patients come into your practice, whether it is a hospital or community practice, you have to become aware, if you were not before, of the complexities that they bring. That is not easy. There are cultural issues in dealing with patients that are very sensitive and difficult. It is not all about those in the community welcoming folk in from outside. It is not only about them understanding and changing; it is also about helping people who come in from outside to understand the community they are joining and the culture and requirements that that community has.

Those are challenges but there are also opportunities, many of which are provided particularly by information and communications technology. They change the way in which young people in particular—though not just them as many older people are increasingly adept at the use of information and communications technology—react to things, receive messages, relate to each other and the way in which we educate our clinicians. It is now possible to educate clinicians at a distance. For example, a skilled surgeon in one part of the country can assist someone conducting an operation on the other side of the world by using telemedicine. We can be in contact with patients in the community by staff using ICT.

Some but not all of this is extremely successful. Just because you have a new gadget does not mean that it is better; just because something works faster it does not mean that it always works better. A colleague told me about a wonderful new system that he wanted to put in that would ensure that immediately the general practitioner made a referral it would be in my inbox. I said that it was no use whatever because the waiting list is still six weeks. It does not matter whether the referral comes in today, tomorrow or the day after, it will still be six weeks before the patient is seen.

Not every piece of technology or new gadget is appropriate, helpful or an effective use of resources. Some approaches can be extremely helpful in allowing us to move on and to learn the lessons about what actually works, which was the whole theme of the noble Lord’s introductory speech. That is crucial but let us not dismiss the importance of research and academic work. It is not just about managerialism, although I do not dismiss that, as in a complex community management is extremely important. I have been encouraged by our new coalition Government’s commitment to get decision-making and responsibility back to the patients, their families, the communities and clinicians of all kinds with whom they deal—it should not be held back at the centre whether that is a management centre, a Whitehall centre or even a governmental centre.

NHS: Patient Targets

Lord Alderdice Excerpts

Wednesday 23rd June 2010 Lords Chamber

[Earl Howe]

My Lords, the noble Baroness is quite right. For example, on the waiting time targets for cancer referrals, we have made no changes because there is a clinical underpinning to those targets. She is also right to say that there is often insufficient information for patients on which to base decisions. We are very keen to build and develop information channels so that patients can be better informed and are able to make better choices about their care.

[Lord Alderdice]

My Lords, is my noble friend aware that one of the difficulties with targets for waiting times was that clinicians were forced to ensure that all patients fitted into the waiting times, when they were aware that some were a great deal more urgent and some not so urgent at all? Can he reassure me that in devolving more power back to clinicians and more opportunities back to local people—patients and carers—those differences between people’s requirements will be taken full account of rather than simply some artificial and arbitrary time limit?

[Earl Howe]

My noble friend is right because, when all is said and done, many of the centrally imposed targets were quite arbitrary. For example, why 18 weeks, not 17 or 19? It is worth saying that the targets that clinicians and managers set themselves are often a great deal more stringent than the ones that politicians are likely to set.

Health: Cancer

Lord Alderdice Excerpts

Monday 21st June 2010 Lords Chamber

[Earl Howe]

The noble Baroness is quite right that screening plays a very important part in the detection of cancer. However, it is not universally applicable to every cancer. In terms of oral cancer, which was the particular subject of my noble friend’s Question, there are difficulties. For example, there is considerable uncertainty about how the disease progresses—its natural history—and we cannot predict which lesions will be malignant and which will not. We need clear guidelines—for dentists, for example—and we do not have those. There is also no clear evidence base for the management of malignant lesions when we find them. However, the National Screening Committee will review its position again in about three years’ time and will no doubt take all the current evidence into account.

[Lord Alderdice]

My Lords, does my noble friend accept that when we are trying to improve treatments for cancer, we are looking for non-invasive approaches and specific and, so far as possible, less expensive approaches? Photodynamic therapy has been very useful not just for oral cancer but for skin cancers of various kinds, particularly squamous cell carcinoma. Does he accept that encouraging not just dermatologists but also general practitioners to move in this direction will mean that we can have specific, non-invasive and generally quite efficient treatment, and that that is to be encouraged by the Government?

[Earl Howe]

I am very grateful to my noble friend. It may help the House if I briefly explain what PDT is. It is a technique that uses laser or other light sources combined with a light-sensitive drug, which in combination destroy cancer cells. When the light is directed in the area of the cancer, the drug is activated. As my noble friend indicated, although this is an invasive procedure, it is minimally so; and its advantage is that, unlike radiotherapy, no cumulative toxicity is involved, so someone can be treated with PDT repeatedly. However, there are difficulties, one of which is that there is no obvious clinical leadership in this field, and that has to be addressed. There need to be centres of excellence in order for the right lessons to be learnt and the right research to be done.

Carers

Lord Alderdice Excerpts

Wednesday 16th June 2010 Lords Chamber

[Lord Tebbit]

My Lords—

[Lord Alderdice]

My Lords—

[Baroness Wilkins]

My Lords—

Health: Isle of Man

Lord Alderdice Excerpts

Monday 14th June 2010 Lords Chamber

[Earl Howe]

My Lords, it might be helpful if I were to clarify the current position. If the noble Lord were to go the Isle of Man, the agreement in place at the moment would enable him to receive emergency healthcare there—that is, healthcare that is immediately necessary—free of charge should he need it. The only reason for requiring travel insurance in addition would be to cover the cost of, let us say, an air ambulance back to the mainland or any extra costs that were non-medical arising out of the emergency. In that sense, the Isle of Man is no different as a travel destination than, let us say, the United States.

[Lord Alderdice]

My Lords, the previous Government rightly trumpeted one of the important advances of the Good Friday agreement: the establishment of the British-Irish Council, bringing together government representatives and Ministers from England, Scotland, Wales, Northern Ireland, the Republic of Ireland, the Channel Islands and the Isle of Man. Did the previous Administration raise this question at the British-Irish Council, which would seem the appropriate place to explore it? If they did, what was the response?

[Earl Howe]

My Lords, I am afraid that I cannot help my noble friend as I have not had access to the papers relating to the previous Administration. However, I can tell him that very cordial discussions and negotiations are proceeding at the moment, and the devolved Administrations will be consulted.

Health: Government Spending

Lord Alderdice Excerpts

Monday 14th June 2010 Lords Chamber

[Earl Howe]

My Lords, smoking cessation is extremely important as a public health measure. I am sure the noble Lord will know that the coalition Government have set great store by their public health agenda. I cannot imagine that smoking cessation is going to disappear off the radar.

[Lord Alderdice]

My Lords, in respect of a number of agencies within the health and social care field, it is clear to practitioners that some of them have been inadequate in their regulatory and monitoring function and others have gold-plated way over the top in a quite counterproductive way. In his search for which agencies could be brought together and their experience shared or which could be changed in other ways, what are the principles that the Minister intends to use to produce a better and more appropriate regulatory monitoring framework within health and social care?

[Earl Howe]

My Lords, there are several principles. A reduction in the number of arm’s-length bodies is only one of the possible outcomes. As I have said, we are not looking necessarily for a large-scale reduction in numbers, but we want to see both efficiency and the delivery of quality. With those two ends in view, the bodies that we end up with have to make sense in terms of what matters in our wider system reform, which is, as I have said, to deliver quality.

Mid Staffordshire NHS Foundation Trust

Lord Alderdice Excerpts

Wednesday 9th June 2010 Lords Chamber

[Lord Alderdice]

My Lords, the immediate response of my honourable friend Norman Lamb in the other place to the 2009 Healthcare Commission report was to call for a public inquiry. My noble colleague the Minister can be absolutely confident of the warm welcome on these Benches to the decision to have a public inquiry, a request that was refused by the previous Government. One has to suspect that it was refused because of the likelihood of exposing the inadequacies not just of a particular hospital and trust board but of the regulatory system that had been put in place and the culture of target and finance-driven managerialism that the previous Government championed.

I am sure that the noble Earl expects that this will be exposed in the public inquiry, but is it not important that we should not only protect whistleblowers—he has announced important developments in that regard—but address the whole culture that regarded professionals and commissions raising questions and concerns as troublesome and disloyal rather than as wanting to improve the standards and quality of the service? What is needed is a change in the culture, so that the views of clinicians of all professions are valued, welcomed and encouraged. The priority of managers is not to dominate the service and to impose politically driven targets but to provide it with high levels of patient care.

[Earl Howe]

My Lords, I agree wholeheartedly with my noble friend that in many parts of the NHS we need a culture change—a culture that puts patients first. We need an NHS that listens to patients and responds to their concerns and needs. We must prioritise the people whom the NHS serves and we must listen to the doctors and nurses who work in it. The measures that we are taking today on whistleblowing are important. Last week, we began to publish more transparent data about the NHS so that people can hold their local services to account in a more meaningful way. We are looking also at reducing the number of hospital readmissions, as I am sure my noble friend is aware.

The culture change that is needed will not happen in a hurry and I would not want to give the impression that it is required everywhere in the NHS. Mid Staffordshire was an unusual event, but unless we get to the bottom of why it happened there must be a fear that it may happen again. As we move forward and propose to Parliament changes in the way in which the NHS is regulated and care is commissioned, we must not lay ourselves open to unintended traps. I therefore concur with all that my noble friend said. I think that he will find, as we bring forward our proposals, that the emphasis on transparency, openness and the patient’s voice will do much to address the concerns raised.

Queen's Speech

Lord Alderdice Excerpts

Thursday 3rd June 2010 Lords Chamber

[Lord Alderdice]

My Lords, several noble Lords have observed how the eloquence, elegance of presentation, experience and commitment of the noble Lords on the Front Bench add greatly to the positive prospects for governance in this new Parliament. The maiden speeches of the noble Lords and the right reverend Prelate also bode well for this as a thoughtful, engaged and reflective new Parliament.

It is a new Parliament and a new Government, but also a new type of Government and Parliament. It was interesting to listen to the noble Lord, Lord Elis-Thomas, and my noble friend Lord Kirkwood of Kirkhope speaking about those of us from the Celtic fringe, who have some experience of these questions. This is one of the marvellous things about our great United Kingdom: it is not all one country with one set of experiences. There are some of us who have experience of fairer forms of voting, which bring different ways of forming Governments. It is interesting now that many of those who said, “We can’t have proportional representation because it will bring coalition government”, now discover that first past the post may also—not only on this occasion, but perhaps in the future—bring coalition government.

One of the things that has interested me and several colleagues from Wales and Scotland is that it is clear that the institutions here at Westminster and in Whitehall, and many of those who are involved in them, have not yet quite understood what coalition government is. It is not merger government. It is not even a political marriage. It is coalition government in which parties bring their own sets of principles and ideas and decide that they will contract to work together for the better of the country. They do not, on that basis, give up either their principles or their policies. Anyone in this Parliament who thinks, for example, that Mr Martin McGuinness and Mr Peter Robinson no longer want to see, on the one hand, a united Ireland, or, on the other, a more united United Kingdom, clearly does not understand much about either the peace process or the politics of my part of the world. If they are sent to the Northern Ireland Office, they will find it a rather rude awakening.

Those of us on the Liberal Democrat Benches have Liberal Democrat principles and policies. We believe that—together, on this occasion, with our Conservative colleagues—we can see those brought into operation. It was gratifying to listen to noble Lords on the other side of the Chamber making clear that they had observed that this Government indeed have a different set of policies than would have been the case had they been wholly a Conservative Government or wholly a Liberal Democrat Government. That is all to the good. It is all part of the new approach to politics that we are seeing develop over time. We saw it in the approach of the previous Labour Government to a number of matters, and we see it going further.

Having heard my noble friends, Lady Walmsley, Lady Sharp, Lord Addington and Lord Kirkwood speak about education, children, sport and welfare, I want to concentrate on health, as it is very close to my heart and experience. I have just retired after working for 30 years in the health service, particularly in mental health. My wife is a pathologist; my brother is a dermatologist; my sister-in-law is a paediatrician; my brother-in-law is a general practitioner; and my sister and her husband are scientific officers in a medical laboratory, so I have some insight into the way the health service works.

The previous Government were undoubtedly committed to achieving fairness in healthcare. They put substantial amounts of money into organising and reorganising healthcare to try to get a good outcome. However, I am afraid that there was a modest outcome and the morale of professionals working in the health service was remarkably low. I give an example. John Reid moved from the Northern Ireland Office—he moved through different ministries—and spent some time in healthcare. He had a notion, which he shared with the previous Conservative Administration, that half the consultants were out on the golf course most of the time. Therefore, he required all consultants to produce a diary showing what they did every half hour for a month, so that he and his colleagues could then clamp down on these lazy fellows and girls who obviously were not paying attention to what they were doing. The result was that consultants began to discover that they were doing far more work than they were contracted to do. They decided that if the Government were going to treat them with suspicion and say, “We will pay you only for this and this”, they would drive a hard contract and reduce their commitment to working only the hours for which they were contracted. The result was a health service contract for consultants that cost the Government more and reduced output, and doctors, who were paid more, having lower morale. It was not that the Government were not committed to fairness—they were—it was a matter of how people were handled and a belief about the way that things work.

Mr Cameron and Mr Clegg have said that this Government will operate on the basis of freedom, fairness and responsibility. Nobody is going to stand up in your Lordships' House and say, “I am against fairness”. We are here because we genuinely want to see a fairer country. However, fairness does not come from the top down through imposition; it comes through freeing and inspiring people. Of course, there is a need for an element of regulation. The noble Earl, Lord Howe, knows very well that I have been working on regulation in psychotherapy for some time. I am sure that he is awaiting the letter that he will get from me in the next week or two which asks if we can have a chat about how regulation in the psychological therapies should move forward. I am not against regulation at all. However, it has to be done in such a way that people feel that they are valued and are not being pushed away from their professional commitments. That is why one of the things that appeals to me about the approach that the coalition Government are taking is that they are saying, “We are not only going to try to work together in this way but we are going to try to give responsibility back to professionals”.

One of the disastrous things that occurred in healthcare happened as a result of it becoming a question of managerial approach and a business ethos. Businesses never produced healthcare in the first instance; it came out of voluntarism, faith communities and professionalism. When you turn it into a business, you eat away at some of the key commitments that people have to this work. They do not do it for the money, but they are not going to do it if they are not paid. They want to make a commitment to people and to feel that it is valued, and they want to feel that those with whom and for whom they work are part of the world which they inhabit.

One way that the Government can get rid of a lot of the funding that is not going to front-line services is by reducing the degree of managerial input and returning a lot more decision-making to clinicians of all kinds—not just doctors—and to patients. We can start this new Parliament not by giving over many of the achievements of the previous Government but by building on the possibility that we can have real change for the better in our politics and in all the areas of work that we have been speaking about today, not least in healthcare.