Health and Social Care Bill
Lord Mawson Excerpts(14 years, 4 months ago)
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Baroness Jolly
My Lords, I can give an example of where it has been provided. Today I have been talking to the operations director of Peninsula Health Care. That was the provider arm for the Cornwall PCT which was providing community hospitals and community services, and which is now a community interest company as of 1 October 2011. It has already brought across all the arrangements that it has with its local authority; Section 75 and so on, shared budgets for equipment, and all sorts of innovative work alongside.
The whole thrust of the amendment of the noble Lord, Lord Rooker, was part of our manifesto, it was part of the coalition agreement, and I feel quite comfortable about supporting it.
Lord Mawson
My Lords, I am very sympathetic to the amendment of the noble Lord, Lord Rooker, for very practical reasons. I am building a street at the moment in Tower Hamlets, and part of that street is not only a new school but a new health centre, which has been under development for five years. The health centre proposals were begun in the previous Government’s time in office. It is true that the Bromley-by-Bow Centre, when competing for that practice, was not on a level playing field. It is very difficult to compete with a multinational company that could undercut the price per patient to £75 per head, when I, having run an integrated health centre for 20-odd years, knew that the real costs were probably around £119 per patient and that the £75 per patient was not sustainable. It was very interesting going through the whole of that process, of proper competition and then losing the competition, to three years later, when I was approached by that company which admitted that the business plan did not work and asked whether we could help rescue the situation, which we have now done, and the multinational business has now withdrawn. I know that there is a problem here that we need to get our heads round, and I know and believe that the Government are serious about wanting the social enterprise sector and the voluntary sector to play their full role. It is a practical problem that needs to be got hold of.
The other thing that I know from experience is that bureaucracies like to talk to bureaucracies. I know that large government departments often find it easier to talk to large businesses. Indeed, we have seen this happen over many years. I am in favour of the private sector. We work a lot with the private sector, and I do not think that it is a case of one of the other. However, I have noticed how easily civil servants translate across into large companies, with the bureaucracy carrying on under other names, and organisations that are leaner and more innovative sometimes find it very difficult to break in. Therefore, if the Government are really serious about allowing some of us who do this work but are smaller in scale to break into this market and grow in capacity, then something will need to happen here to help that.
I also know from experience that one way in which we have grown in capacity is by forming relationships with one or two businesses. They have got to know what we are about and we have got to know what they are about, and we have formed partnerships and grown opportunities together. As I mentioned earlier, a £35 million LIFT company has now built 10 health centres. When we formed that relationship, which is a bit like a marriage, we got to know about each other’s worlds. We are now in a social enterprise with that business carrying out landscape work on 26 school sites. Therefore, there are things that government can do.
In my experience, some businesses are becoming more intelligent about this, although some businesses are not. The Government should be using their muscle to encourage businesses to form these local partnerships. If they do not do that, the danger will be that the profits made in poorer communities will be sucked out of the area, rather than there being virtuous circles around the areas creating more jobs and opportunities in local contexts. Therefore, I am sympathetic to the amendment. I would encourage the Government to look again at some of the practical issues and how they work in practice on the ground.
Lord Beecham
My Lords, for centuries what is now termed the voluntary or charitable sector was the main provider of health services in this country. It is a common view across your Lordships’ House that the sector must be encouraged to play a growing part in the provision of services, partly because it has a track record of innovation, is less inhibited by cumbersome regulations, and perhaps, as I have said on a previous occasion, is a little less risk averse than public bodies tend to be and obviously less motivated by the profit motive than the private sector necessarily has to be.
Surely it is common ground that we want to see a thriving voluntary sector, and I credit the Minister with sharing that aspiration. The trouble is that the Bill does not help him to do that. At best, this clause is neutral in its attitude towards the voluntary sector and, at worst, it will conceivably endanger the realisation of that aspiration. The noble Lord, Lord Greaves, pointed to the curious phrase in paragraph (b), seeking some elucidation, which we may get. However, as it stands, that paragraph could easily be interpreted as referring to the charitable and voluntary sector and as placing that sector at a disadvantage because it would be brought within the scope of the provisions of the clause, which would prevent any positive discrimination—if I might put it in such terms—in favour of that sector. That may not be the intention but it would appear to be very likely to be deemed to be the outcome.
There are already significant inhibitions, as a number of your Lordships have pointed out. The noble Lord, Lord Rooker, referred to the central Surrey experience, where a £9 million performance bond was requested from a social enterprise which clearly was not able to provide it. Incidentally, I contrast that with the financial position of Circle, which had a £45 million pre-tax loss in the year prior to the award of a contract to it and apparently very little relevant experience in running a hospital facility. However, it was awarded a contract. It would be interesting to see what criteria would be applied in future cases of that kind, whether to social enterprises, enterprises purporting to be social enterprises, such as Circle, or other enterprises. Be that as it may, there are clearly considerable difficulties for the social enterprise sector. Social Enterprise UK in its briefing, which no doubt some of your Lordships will have had, points out that the clause could also prevent the continuation of policies such as the Social Enterprise Investment Fund, which helped to support social enterprises in their endeavours.
The noble Baroness, Lady Williams, bravely interposes herself between the raging Opposition and the beleaguered Minister—as he appears to deem himself—but for what purpose I really cannot quite understand. Nobody is doubting his bona fides; the question is whether the legislation reflects his intentions. The very best that can be said of the clause which the amendment of the noble Lord, Lord Rooker, seeks to improve is that it creates a neutral situation. However neutrality, like patriotism, is not enough in this context. If we want to support the sector then we have to recognise the disadvantages with which it starts and not go for a simple level playing field on the assumption that all parties on the field are equal. We have to prepare the ground to assist this particular sector. At the moment, I do not think that the Bill provides for that.
The amendment does not require the board to favour the sector. I might have gone along with it had it done so. It provides the option for the board to assist the sector in making its particular and distinctive contribution to the provision of health services and removes what would be a substantial obstacle to that happening. This clause reflects a positive attitude to a sector that needs that kind of support. I therefore hope that the noble Earl will accept the suggestion made by my noble friend Lady Thornton in the earlier debate and hold some kind of discussion with representative bodies such as ACEVO, which is clearly concerned. The chief executive of ACEVO was a member of the Future Forum and his views should be taken very seriously. There are other organisations, some of them already in the field providing services, which clearly have an interest in this. The hospice movement, which has been referred to, is a very good example. A meeting convened by the Minister would be very helpful in that respect.
Social enterprises are perhaps slightly different from traditional third sector organisations. They are essentially a new form of enterprise in this field and again they ought to be represented at such a discussion. At the very least, I cannot see what the Minister would have to lose by accepting the noble Lord’s amendment. It does not impose a positive requirement. It does not prevent other parties being involved in undertaking work or competing for the provision of services in this area, it merely provides for a third option. If that is consistent with the Minister’s approach I cannot see what the Government have to lose by accepting it. It certainly is no reflection on his intentions, as I am sure the noble Lord would confirm and as I have repeatedly said. I therefore hope that the Minister can respond positively—if not tonight by simply accepting the amendment, which would be the easiest and most preferred course for many of us, then at least by entering into discussion with a view to assessing the degree of difficulty that the sector fears would arise from this provision. We could then see on Report whether we might amend the clause something along the lines of—if not on the actual lines of—what the noble Lord, Lord Rooker, has proposed. That would meet the wishes of all Members of this House to see a thriving sector contributing in that mixed-economy provision to which we all subscribe.
Lord Mawson
My Lords, I would certainly be willing to help with this. It is one thing to talk to representative bodies: that is fine. However, the Government might find it helpful to talk to individuals who have dealt with the nitty-gritty, practical realities of the situation, and who may have practical insights that could help the Minister with some of these issues. I would be willing to suggest one or two people if that would be helpful.
Earl Howe
My Lords, I have had a lot of helpful comments in the debate and very much welcome the chance to reiterate the Government's support for the work of the voluntary and community sectors. The noble Lord, Lord Rooker, is absolutely right; these organisations have a very important role to play both in the provision of support to patients and their families, carers and communities, and increasingly in the provision of services. It is right that the NHS Commissioning Board and clinical commissioning groups should be able to provide funding to support them in this work. The noble Lord suggested that the effect of the Bill would be to snuff out the third sector. I assure him that that is not so.
I will quickly clarify the effect of the duties relating to market share. We want the NHS to operate around the needs of patients. That is why patients’ interests are at the heart of the Bill. Healthcare services should be commissioned on that basis and not on the basis of who is providing the care. This will not prevent a range of work that may go on to support the voluntary sector where it does not directly provide healthcare services. I believe that the Bill goes further than any previous legislation to remove barriers standing in the way of a fair playing field. I do not and will not shy away from our commitment to see a vibrant third-sector market in the NHS.
I will provide a little detail and flesh on the bones. The Bill already provides the board and clinical commissioning groups with the power to make payments through loans and grants to voluntary organisations that provide or arrange for the provision of similar services to those that the board will be responsible for commissioning. This power mirrors the power that the Secretary of State has under Section 64 of the Health Services and Public Health Act 1968, currently exercised by strategic health authorities and primary care trusts. The power would not apply only to service provision. The board and clinical commissioning groups may also want to fund work that will assist in the effective commissioning of services. For instance, the board may provide funding to voluntary organisations with particular expertise in the provision of support to people with rare specialist conditions to guide its approach to commissioning those services. Grants and loans of this sort will support innovation and vibrancy in the health sector and we want to encourage this.
I reassure the noble Lord that we expect that the NHS Commissioning Board and clinical commissioning groups will also continue to uphold the principles set out in the compact. This remains a key agreement between the state and the voluntary sector. Local commissioners should make every effort to engage their voluntary and community partners in discussion on priorities and the allocation of resources, working in a way that is transparent and accountable to local communities. I know that that is already happening at the level of pathfinder CCGs.
The noble Baroness, Lady Armstrong, chided the Government by saying that their rhetoric had not been followed through into action. I say to her that voluntary sector grant schemes are still in place. These are the innovation, excellence and service delivery fund, the strategic partner programme, opportunities for volunteering and the health and social care volunteering fund, under the collective umbrella of the Third Sector Investment Programme. The total value of this for the current year is £25 million. It will continue in 2012-13, which will ensure the continued support of its member organisations to build their capacity and capability to make high-quality and responsive contributions to support health and well-being in our communities. A £1 million financial assistance fund opened on 20 December last for organisations that make a significant contribution to health, public health and social care, but which are most at financial risk. In addition, the department contributed to the Office for Civil Society’s transition fund.
As I say, the department greatly values the voluntary sector’s contribution and our ongoing support for the grant funding programmes through this year recognises the increased role of the sector in helping us renew our efforts to build strong, resilient communities and improve health and well-being outcomes. What I cannot precisely do at the moment is say how much money will be available next year. Decisions about budgets for 2012-13 will be made in due course and we will work within the principles of the compact in making those decisions.
I hope that what I have said has served to reassure the noble Lord, Lord Rooker, that we are serious about this and indeed I hope he will accept from me that nothing in the Bill interferes with our purpose to support this important sector. Our policy is that services should be commissioned from the providers best able to meet the needs of patients and local communities. That is the key. Unfortunately, the wording of his amendment, if taken literally, would run counter to that principle, which is why I am afraid I cannot accept it, but I hope he will find some comfort in what I have said.
Health and Social Care Bill
Lord Mawson Excerpts(14 years, 4 months ago)
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Baroness Cumberlege
My Lords, I have tabled three amendments in this grouping: Amendments 110C, 131A and 190C. I am grateful to the noble Lord, Lord Patel, for supporting the amendments because they concern maternity services, and I do not think I could have anyone more distinguished than the past president of the Royal College of Obstetricians and Gynaecologists, although of course the noble Lord is also involved in many other things, not least this Bill. These are probing amendments, the first of which seeks a commitment from my noble friend the Minister that the Government, through commissioning at the national and the local level, will give women and their partners real and informed choice in maternity services. The second amendment would ensure that there is less variation in the quality of services provided, and the third concerns maternity networks, including independent midwives.
The variation in maternity services across the country is quite startling. Sometimes the poor performance is a reflection of a lack of resources or priorities, but one of the reasons for this is that maternity services have been overwhelmed by the rising number of births, including more complex cases. This is partly due to the increase in the number of older women giving birth. Last year the number of women giving birth aged over 40 was the highest since 1948, the post-war period, and we can surmise about that. In the past 10 years in England, the number of births overall has risen by 22 per cent, which means that more than 10,000 extra babies are born every month. There has been a modest increase in midwives, and we should be grateful for that, but they are being run ragged by this record-breaking baby boom.
The Bill seeks to ensure that the quality of NHS services will improve by using new and increasingly much more sophisticated commissioning systems. If this key objective is to be realised, it will require commissioning of a very high quality. Pathfinder clinical commissioning groups are beginning to get a grip and to understand the health needs of their local populations, but inevitably others will lag behind and we will see variations in commissioning. One of the ways to address this is through a NICE quality standard, as already discussed by the noble Lord, Lord Butler, and my noble friend Lord Newton. But as the noble Lord, Lord Walton, said, even when these standards are produced, advice from NICE is not always adhered to, and I understand that the queue for these quality standards to be produced is very long, with maternity services some way down the line.
On quality, proposed new Clause 13E(1) states that the NHS Commissioning Board should improve the quality of services in three areas: prevention, diagnosis and the treatment of illness. On prevention, however powerful the board is, it is going to find it a real task to prevent wanted pregnancies—even Solomon in all his glory failed to do that, and he knew quite a bit about babies. On diagnosis, I do not think there is much problem in diagnosing pregnancy, as it is usually pretty obvious to those concerned. On the treatment of illness, certainly most women who are pregnant are not ill; on the contrary, many take enormous care of themselves and are extremely fit and so will not need treatment for illness.
Looking at those three criteria in that subsection, I think that they do not fit with maternity services. Therefore, we have a lacuna, which I am trying to fill with my first amendment. I suggest that the Commissioning Board keep a watchful eye on the situation in England and use a means—possibly a specification or some other mechanism—which would act as a guide to enable commissioners to buy services from NHS trusts at a set quality, until NICE has produced its quality standards.
My second amendment concerns choice. I apologise because I think it has been positioned rather wrongly in the Bill, but it is another probing amendment.
“Pregnancy is a long and very special journey for a woman. It is a journey of dramatic physical, psychological and social change; of becoming a mother, of redefining family relationships and taking on the long-term responsibility for caring and cherishing a new-born child. Generations of women have travelled the same route, but each journey is unique”.
I wrote that in the foreword for Changing Childbirth, which was a government policy document that I produced many years ago. It is because each journey is unique that women and their partners should have as much choice as possible, because we know choice is empowering. Giving birth can be wonderful, but it is also very traumatic and the start to a new life can have long-term consequences for the baby as it enters childhood and later adult life.
New Clause 13I, places a duty on the board to enable patients to make choices in the services they receive. Pregnant women and their partners have four main choices when considering where to give birth: at home, in a free-standing midwifery unit, in a midwife-led unit situated alongside a hospital or in a hospital led by a team of obstetricians. This is the theory, but it does not actually work in practice. Delivered with Care, a national survey of women’s experiences of maternity care in 2010, undertaken by two very respected researchers in the field, found:
“Many women (80 %) were not aware of the four possible options for … birth”.
Therefore, how can potential parents choose when they are not even aware of the options? Why do health workers, especially GPs, seeing a woman at the first booking, not tell them what is available? The majority only tell them where to go, and that is hospital.
In a joint statement the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives, in their introduction to a paper on home births state:
“The rate of home births within the UK remains low at approximately 2%, but it is believed that if women had true choice the rate would be around 8-10%”.
It is part of government policy to give choice, including birth at home, to every pregnant woman. In Somerset 11.4 per cent of births are at home, whereas in Wansbeck the figure is just 0.1 per cent. Of course there may be a range of factors affecting this—I suspect housing and other conditions also play a part—but this discrepancy is so great that I am sure it is partly due to the fact that mothers were not even told what was available. I would like to ask the Minister how he sees the NHS Commissioning Board addressing its duty in new Clause 13I as to patient choice in maternity services. I appreciate this is quite a minority sport so the Minister may like to write to me on this issue.
My third amendment concerns maternity networks. Neonatal and cancer networks, where they work well, have proved to be highly effective. It is a model that those in maternity services wish to adopt. They believe that effective, inclusive and supported maternity networks have the potential to ensure that all women, within the network locality, are able to access the full range of services from pre-conception to early years. The networks would be able to promote choice within these services and work with all providers to ensure that women are offered and are able to exercise informed choice. The existing networks have received funding for their infrastructure, which has enabled them to be effective. Will my noble friend consider a similar commitment from the Government to support the development and sustainability of maternity provider networks and ensure that they are properly resourced?
Part of the network should be the care offered by independent midwives, who give a highly specialised and personalised service, accompanying the family through this wonderful but often stressful time in their lives. There are around 130 independent midwives in the country, but there are about 800 who would choose to work in this way if they could get professional indemnity insurance. Currently that is not the case because of market failure to provide for it.
The EU Council of Ministers has issued a directive on patients’ rights on cross-border healthcare that requires member states to ensure that systems of professional liability insurance are in place for treatment provided on their territory. The Government ratified this directive on 28 February this year, which means that all midwives in independent practice in the UK will need to be able to access this insurance from September 2013 in order to be registered with their regulatory body, the NMC. Without registration, they will not be able to practise midwifery legally; independent midwifery will disappear, unless a solution to the insurance conundrum is found. Can we really afford to let this happen when the maternity services are in such desperate need of experienced, skilled midwives?
The clock is ticking and the issue is urgent. I ask my noble friend, who is well aware of this difficult issue—we have met in the past to discuss it—to tell me when the Government are planning to publish their proposals and when independent midwives and other non-NHS bodies will be able to take up the NHS clinical indemnity arrangements planned for by the Government.
Lord Mawson
My Lords, I rise to support Amendment 131A proposed by the noble Baroness, Lady Cumberlege. My wife and I have three children and have experienced some choice as to whether they were born at home or in hospital. I must admit that this was not a matter to which my wife and I had given a great deal of thought when we had our first child 31 years ago. Then we naively assumed that having a child in hospital was fine and the normal practice. The doctor would look after us. However, the truth is that it was far from normal for a young married couple. We discovered later that everything that was done seemed to be focused not on the well-being of the patient—my wife and child; some would say the customers—but on the interests and timetable of the consultant. Medication was given that was not really needed to ensure that the child was born to fit some preordained hospital schedule, a timetable that I think had more to do with the consultant’s golfing schedule, I discovered later, than the interests of the mother and child. The experience left some scars.
Our second child was born at home in Tower Hamlets, under a new home birth scheme that was quite radical at the time and which was set up by Dr Wendy Savage. I must say that this experience was completely different. We all felt so much more relaxed and in charge of events, as best you can be on such occasions. It all happened rather quickly and in a relaxed atmosphere and was an experience of great joy for us all. The effects of this experience on mother and child, with a competent midwife present, were quite different. I must say that even I felt quite competent in making the tea. The first experience in hospital had all been about a culture of illness at the most important moment of parents’ lives; the latter was about health and well-being.
Health and Social Care Bill
Lord Mawson Excerpts(14 years, 5 months ago)
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Lord Mawson
My Lords, I am a social entrepreneur who, for 25 years, has danced with the dinosaur-like structures of the NHS. I have had my feet trodden on many times, as colleagues and I have attempted to bring some innovations into primary care. We know from personal experience how difficult it is to bring about a more integrated service and innovation within such bureaucratic and out-of-date structures. The vested interests in the BMA and elsewhere in keeping things unchanged and unchallenged are considerable. At the same time, a nostalgic view of the NHS prevails which is anti-business, but which fails to recognise that most GP practices are small businesses and always have been. Let us be honest. I, for one, wish the Government well with their difficult task in bringing much needed change to the NHS.
While many colleagues will have a lot to say about the new proposed structures in primary care, I will make a few simple but fundamental points that appear to have been overlooked. In my experience, trying to change very large organisations—in this case one of the largest in the world—takes time and a great deal of patience. It will involve getting behind those more entrepreneurial doctors who embrace innovation and a more integrated view of the world. In the experience of my medical colleagues, the offer of the biomedical model alone in primary care is too limited an approach for the kinds of health needs that are presented daily. A more integrated and holistic approach is needed, one which sees a human being as not just a bio-medical machine but a fully rounded integrated person set within a social context. Yet many GPs who are committed to positive changes and who are working with the Government to attempt to bring them about are feeling bamboozled by the torrent of paperwork that is being thrown at them by out-of-date anachronistic structures which only know one game—the old game.
In a culture where people are increasingly, through the use of technology, living in an integrated world where at the push of a button many choices present themselves, it will be difficult for this new generation of entrepreneurial GPs to create a flexible structure and innovative culture in the NHS, which is still dominated by silos and an ideology of health inequalities—an ideology which sounds very fine in theory but which, in practice, has many unintended practical consequences that do not favour the patient.
The entrepreneur Steve Jobs, founder of Apple, who has just died knew that technology can be the way into culture change and his technology has created a wholly new generation who no longer want silo-like responses to their problems but at the touch of a button to find an integrated solution.
I would like humbly to suggest a few small simple innovations that the GPs I work with inform me could make an enormous difference to both practice and culture as we seek to push the NHS forward. I have found that the way into large, seemingly immovable structures and organisations, as an entrepreneur, is often through small, simple things that make a big difference. I therefore ask the Minister the following simple, but vital, questions. First, why has the iPad not been used in hospitals and by GP practices and district nurses as a simple integrated communications tool? Secondly, why is it that a GP in Tower Hamlets cannot Skype a consultant in the London Hospital with the patient by their side? Everyone is increasingly using Skype in the real world to communicate and it is free. My medical colleagues tell me that 99 per cent of their patients see no problem with confidentiality rules. We need to remove a system and ideology that makes simple, obvious tasks so complicated. Thirdly, why is it that chest X-ray forms are different everywhere you go in the country. Why are they not uniform and available everywhere online? Fourthly, why have neither the Department of Health nor NICE produced a standard referral form for all types of referral to hospital?
I am a great supporter of the Government’s decision to go local, but as an entrepreneur I know, as do my GP colleagues, that there is a whole raft of things that do not need to be developed in every part of the country. It is too expensive and unnecessary. I am told that there is a whole raft of rules stopping the modernisation of the NHS. When innovators like me attempted to cut through these rules in east London in some of the poorest housing estates in Britain, I was told by some at the time that the sky would fall in. It did not and the offer to patients improved. This institution desperately needs innovators, not more bureaucrats.
My colleagues and I are attempting at this time to build a new health centre in one of the most difficult housing estates in London—and here I must declare an interest—which is part of an integrated project on a particular estate that includes both a new school and 500 new homes. Every key partner is supporting the project but it is the outdated, overly bureaucratic systems and processes of the PCT that are simply getting in the way. There are some good people in this PCT, but I cannot imagine how they keep their sanity in such structures. I know this is a widespread problem as many people are retiring early across the country and there is far too much sick leave in the NHS. Ill structures make people ill.
How do we make the simple things happen that catalyse the changes that are necessary and make it worth coming to work for? How do we modernise the NHS and give GPs the tools to do it? I suggest that some of this is about enabling them to just use the simple tools of technology that you and I use every day. It is about giving civil servants permission to get behind innovators.
I would like to leave your Lordships with a final clue. Steve Jobs at Apple did not go around asking all his customers what they wanted. He did not consult them to death. He believed that if the product was good enough for him, it was good enough for them. The real test for those who oppose this Bill is: would you walk into the average inner city London GP practice and register yourself as a patient? Would you as a patient rank the quality of care provided there as high? If the answer to these two questions is no, then you need to embrace change within the NHS. Jobs achieved what few politicians do. He embraced entrepreneurship and innovation and created real and sustainable change. He focused on creating small innovations in technology that worked well, and then offered them to the world. On his sick bed, he showed a commitment and attention to detail that I have yet to see in many politicians and civil servants. The easiest way into the NHS impasse is simply to back those GPs and nurses who are not threatened by this new emerging world but who embrace it and grasp it with both hands.
We must back the innovators with a sense of purpose. Learn from those who make change happen. Is change going to be difficult? Will this Government get some things wrong? Yes. Innovation is always like that. The question is: can the organisation learn from mistakes? Can it learn by doing? Can it start walking instead of talking? You cannot hold back the ocean; let it flow.
NHS: Reorganisation
Lord Mawson Excerpts(15 years, 3 months ago)
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Lord Mawson
My Lords, I thank the noble Lord, Lord Touhig, for securing this debate. We are entering one of the biggest reorganisations of the health service since 1948 by passing budgets and power locally to GPs. I welcome this move. However, difficult questions must be asked, not just about how we can more efficiently manage, organise and run the health service but about whether the story that we tell as a nation about our health is true, life-giving and sustainable.
In the health debate in October, I asked how we could provide quality healthcare that meets the real needs of patients in today’s world. Is the popular biomedical model of health in which we invest good for our health and sustainable? Will it help those most in need, or does its internal logic present us with a costly and limited view of what a healthy human being is?
The GPs with whom I work tell me that in deprived communities such as Tower Hamlets 50 per cent of the patients whom they see do not need a doctor. One GP at an NHS walk-in centre told me that, out of the 80 patients he saw in one day, only 20 really needed to see him. A nurse told me of one patient who came into her surgery last week to ask her for hand cream on the NHS rather than buying it at the chemist. Let us tell a story about the personal responsibility of patients. Often, “patients” do not need a doctor; they need something else. What presents itself as a health issue may be more to do with a patient’s isolation or the need for a better job or lifestyle. People have bought into a culture of illness because it costs them nothing, but in reality the cost to our society is running into millions of pounds. A Times article this week stated that 7 million patients failed to show up for hospital appointments in the past year, costing the NHS millions of pounds. If those 80 patients at the clinic had had to pay £5 each to see the doctor, they would first have asked themselves, “Is this visit really necessary?”.
A sensible balance and perspective need to be found. There is a cultural belief that there is a pill for every ailment, and that if there is not there should be. We are in danger of medicalising people out of existence and creating levels of anxiety that have unintended consequences. Only last week, “experts” advised those of us over 50—I declare an interest here—to take an aspirin every day, but the sting in the tale was that, for some of us, it might mean bleeding to death internally. I am in danger of becoming a nervous wreck.
We must return to the question that the innovative Dr George Scott Williamson from the Pioneer Health Centre in Peckham asked all those years ago before the founding of the NHS: “What is health?”. Although we love them dearly, the BMA and their powerful allies in the medical profession have many financial and other interests in keeping the health narrative unchanged and unchallenged. Our health is matter not just for our doctors.
Most of us engage with the health service through primary care and not, fortunately, through the acute sector. It is in preventive medicine in primary care that limited funds can have the most impact. Some fantastic innovative attempts in preventive health care have been made, and some successes achieved, by using the power of modern media to change behaviour. Jamie Oliver, a well known social entrepreneur—not a doctor—challenged our preconceptions about unhealthy eating. The Government have published an excellent white paper on public health, Healthy Lives, Healthy People. It underscores the importance of preventive actions taken at the initiative of the community and local businesses.
My colleagues and I have radical plans for a social business to regenerate communities in east London through good food—I declare an interest here, too. We want to teach non-cooks how to cook in their communities and young mums how to create healthy meals for their children. We have partnered with Jamie Oliver’s team and the most well-known academics in the field. We also have support from the local NHS. However, obtaining start-up grants to support this work has not been easy. We suspect that this is because we are unashamedly a social business and not a charity. Why are innovative projects such as this, with all their potential for cost saving, still so hard to get going? Why are more innovative partnerships such as this not being brought together by local GPs and social entrepreneurs? It is because they live in different worlds, and because government and charitable funding silos discourage cross-fertilisation and make it so hard to do. New thinking comes not out of theoretical clouds but out of novel and unexpected practical partnerships. Yet the present professional structures discourage this. Why?
What might a new health narrative sound like? First, the NHS needs to tell a story about a changing demography and the financial realities that lie behind it. We have an ageing population and a health system that is unsustainable. Let us tell people the truth. We all need to take more individual responsibility for our health. The NHS should be a supportive shoulder on which to lean, if and when required, instead of encouraging a dependency culture and maintaining its present stranglehold.
Secondly, Governments must tell a new story about the importance of preventive medicine and illustrate it by telling the stories of GPs who are now forming relationships outside the box. Governments must be more honest with us all and stop feeding on papers, statistics and structures that can magically be manipulated to tell them exactly what they want to hear. They go home happy; the patients do not.
Why not start asking how government can help to bring together doctors and social entrepreneurs, innovators, artists and creative people in shared health buildings so that we develop innovative approaches to basic health care and prescriptions that meet people's real health and social needs? This is not about new money but about asking how money that already exists in local communities can be brought together in a more integrated and efficient way. Let us bring together practitioners from different disciplines into the same building and move beyond the collocation of services to integration. We have in east London.
Thirdly, let us tell a story that admits that ploughing vast amounts of money into the health service does not inevitably improve people's health; it can have unintended consequences. People in poorer areas still die seven years earlier than in richer areas, and health inequalities between rich and poor are getting progressively worse, even after all the investment in recent years. More money is not necessarily the answer. We need to think more imaginatively than this.
I leave a couple of questions for the Minister. How in practice is government going to use the restructuring of the health service to create a new narrative relevant to modern health? Secondly, what is government going to do to ensure that doctors engage with innovators and entrepreneurs?
Healthcare
Lord Mawson Excerpts(15 years, 5 months ago)
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Lord Mawson
My Lords, I want to make a few points about health and social care. How do we provide quality healthcare that meets the real needs of patients in today's world? Will the popular biomedical model of health meet all those patient needs, or does its internal logic present us with a limited view of what a human being is and provide us with an expensive approach to healthcare? Is what we say that we believe about health believable?
The GPs I work with in east London tell me that in poor communities such as Tower Hamlets, 50 per cent of the patients they see do not actually need a doctor; they need something else. What presents itself as illness may actually be more to do with a patient's isolation, the need for a friend or a job, better housing or a more creative lifestyle. In such cases, attempts to find a magic pill or potion are inappropriate and a waste of resources; GPs and patients need our help.
In this new financial environment, there is an opportunity to begin to open up a more integrated and cost-effective approach to healthcare at a national level which builds partnerships between health and social care professionals and with the voluntary and social enterprise sectors, but it will require encouragement and leadership from within government if this more integrated and cost-effective approach is to work.
GP practices are anchors in local communities that could play an important role in the development of the big society. Four years ago, I was asked to intervene by the then CEO of the local authority in St Paul's Way in Tower Hamlets, which is a single street in one of our most challenged housing estates. I am now leading the St Paul's Way transformational project, so I declare an interest in this project, but I am pleased to say that it is fast becoming a pathfinder used to illustrate the benefits of joined-up working. We are now exploring the possibility of creating a community interest company, which in time may manage the facilities along the whole street. When I first arrived on the street, I was shocked to discover that there was the possibility of developing a new £40-million school under the BSF programme, a new health centre across the road and 500 new homes. So what was wrong? None of the key players in health, housing or education were talking to each other.
The new focus on patient-led healthcare could result in new relationships between doctors and health professionals and local members of the voluntary and social sectors. This more integrated approach is important because, at present, strategy is running on departmental lines. Education is introducing free schools, health is devolving budgets to GPs and social services are extending personalisation budgets. Society does not operate along departmental budgets. Go to any town or city district and ask the police for the top 100 families that they routinely deal with for anti-social behaviour. Ask the GPs who are their most demanding patients; ask the housing office and the courts. The same names will keep appearing. Despite decades of rhetoric, the same tragic newspaper headlines will keep appearing—baby Peter being one horrifying example.
Unlike the initiatives of the previous Government where the state was encouraged to be joined up, my colleagues and I would suggest that the state will never be joined up and that the answer is to let communities and local organisations, such as GP practices, join up on local streets to deliver joined-up services. I am encouraged that this is the direction that the Government seem to be taking us. We must take the opportunities that this presents. I suggest that in this financially strapped environment there is a new opportunity to turn this old health logic on its head. But the Minister will ask how we are going to do this and how we will create the physical environments on the ground within which this can take place.
One answer is already there; namely, LIFT, the Local Improvement Finance Trust. We could do a great deal with this, but there is not time to go into the detail. I leave the Minister with one question: will he tell the House how he proposes to encourage GPs to take up the opportunities presented by the transfer of funding to GP practices? What is the Government’s plan for general practice to play in the creation of the big society?
Health: Primary and Community Care
Lord Mawson Excerpts(15 years, 9 months ago)
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Lord Mawson
To call attention to practical lessons from changes in primary and community care during the last 10 years; and to move for Papers.
Lord Mawson
My Lords, it is a privilege to be able to lead this debate on the future of primary and community care at this early stage in the new coalition Government. The vision that the Government have set out for primary care, where resources are deployed in the hands of practitioners close to the ground, has significant risks but is full of opportunity. As a social entrepreneur, I welcome this bold step.
As noble Lords will know, over the past 13 years in an area of great deprivation and health need, where the health authority had left a gaping hole in primary care provision, we, with the local community of Bromley by Bow, have set up a health centre which is integrated with housing, education, businesses and the arts. I declare an interest as the founder and, now, president of the centre, and that, in my professional life, I am increasingly working across the country advising on this area of health development.
The Bromley by Bow Centre is about health, not sickness, which is reflected throughout the building. You enter through a beautiful cloistered garden, recently full of purple wisteria. There are no gruesome pictures of human bodies on the walls greeting our patients, the kind of images that used to haunt me as an imaginative eight year-old at our local doctor’s surgery in Bradford. Instead, you walk into an art gallery and open-plan reception made of natural timbers and bathed in natural light. A high-quality environment, a focus on human relationships, open communication and customer focus are the keys to the Bromley by Bow approach. Doctors come out into the reception to chat and greet their patients in person. In the consulting rooms, patients and doctors sit side by side around curved wooden tables, looking at the computer screen together. At Bromley by Bow, doctors, nurses and patients work in partnership together.
Patients are not merely prescribed pills, referred and sent on their way. The drug we give to a patient with depression is only part of what our GPs prescribe as a fully comprehensive care programme. At the centre, we can offer on-site career advice; support to overcome debt; vocational training qualifications, and even a university degree programme; business support, including the opportunity to set up your own business; and practical housing and legal assistance.
Over the past 13 years the Bromley by Bow Centre has become an exemplar of an integrated approach to health and social care. It inspired the £300-million healthy living centre programme, run by the then New Opportunities Fund, and the £2-billion NHS LIFT initiative, which is of course the public/private partnership programme for building primary health and social care centres in the most disadvantaged areas across the UK.
Others have developed integrated approaches to health in other parts of the country. Dr Angela Lennox built a police station in her health centre in Leicester and reduced crime in the housing estate where it is based. The Westbank Community Care Centre in Exeter promotes healthy living across Devon. The Gracefield Gardens health centre in Streatham works in partnership with Lambeth PCT and Lambeth Council to deliver better healthcare. We ourselves now run three health centres for over 18,000 patients and are the largest primary care provider in the London Borough of Tower Hamlets.
I apologise for not being able to speak last week in the debate on the big society, but are these not all examples of where, in the micro, a big idea like the big society might take root? If integrated models of health and community care were encouraged in every community up and down the land, and the necessary local relationships and partnerships brought together, this important idea—the big society—might not become subject to yet further cynicism and be seen as more meaningless government spin with little substance underneath. It might actually become the fertile ground within which a wholly new definition of what it means to be a healthy society—a thriving community—took root. Of course, such an approach would need to be given time and consistent leadership.
There is a wealth of untapped social entrepreneurial talent in our country. Many of these entrepreneurs have it in them to generate creative and innovative approaches to primary and community care. There are hundreds of latent and undernourished third-sector organisations in this country with the capability to become like Bromley by Bow and take on the task of transforming how public services are delivered in communities up and down the UK. Our task is to find these people and organisations and put the wind in their sails. Over the past 10 years I have travelled up and down the country and discovered social entrepreneurs who are massively frustrated at how hard it is to be trusted and resourced to take on public contracts, including in the areas of health and social care. Despite the positive rhetoric from successive government Ministers, it has been intensely difficult for dedicated and talented social entrepreneurs to develop creative solutions.
My noble friend Lady Finlay and I offer the Minister a visit to some of these centres and the opportunity for him to see in detail what a successful integrated approach to health and community care actually looks like in practice, and what conditions need to prevail if it is to grow exponentially and to take root. The sad fact remains that these examples of an integrated health model are still few and far between. Despite all the rhetoric and promises, there has been little practical encouragement for these integrated approaches to health. It was ironic that our approach, which everyone now thinks is a great idea, was physically blocked by a boulder across our road to delivery back in the mid-1990s. The boulder was not local people but the local health authority at that time.
I am not convinced that things have moved on much. Yes, money has been spent on building new buildings and, yes, there has been investment in services, but the principle of broadening the base of primary and social care delivery and engaging social enterprises has barely been understood. I am aware that the language of social enterprise is spoken inside Whitehall, but I am profoundly doubtful as to whether it is understood. Indeed, the evidence is that it is not. Our public services need to be known for doing and achieving, not just endless talking, restructuring or writing yet another new stack of policy documents. In a modern enterprise economy, we are nowadays returning to the sensible practice of “learning by doing”. The idea that we learn much through the writing of endless documents that are out of date within weeks can seem rather outdated. There is nothing better than getting your hands dirty in the practicalities to really understand what is going on. When I spoke to the recently departed chair of NHS London, he told me that his mission was to build stand-alone “medical model” health centres without what he called “the distraction of social and community care”. Evidently, the complications inherent in the lives of disadvantaged Londoners were outside the brief of the chair of NHS London.
Similarly, the vision of the noble Lord, Lord Darzi, of a network of polyclinics, announced in your Lordships’ House, was in practice another missed opportunity. When you get into the practical detail with those of us who are practitioners, you see that it was not at all a vision of polyclinics, but of monoclinics—that is, health centres that are almost solely about the clinical model of healthcare. It is a sophisticated clinical model and, invariably, these clinics are full of state-of-the-art equipment and procedures. However, I am vexed to say that they pay scant lip service to the lessons many of us have learnt about integration and the bringing of different disciplines together in the way I have described—that the route into addressing the pressing and underlying health needs in some of our most challenging communities in this country lies in getting GPs to work with their non-health colleagues. It is as simple and as complicated as that.
We need our health service to be open to working in partnership with the third sector and social enterprises in integrated schemes which address the real, practical day-to-day issues that face patients. These include poor social housing, underachievement in education, credit card debt and fear of bailiffs, concern over street violence and anti-social behaviour, and the lack of opportunities to take control of their lives. We are not asking the NHS to solve all these problems. We are simply asking that the health profession be willing to work more collaboratively with others who have the tools to change our communities for the better, including by addressing their physical and mental health needs.
What those of us who have had real experience of running successful integrated health centres found was that the definition of a polyclinic changed on a six-monthly basis, and each new definition was communicated by NHS London with such clarity and certainty that real players and practitioners in the field were left totally paralysed. This meant that important health centres still remain not built, with enormous potential abortive costs. I know of one health centre that has had to go through so many NHS London-inspired redesigns that it has incurred over £1.5 million of design fees and still sits in NHS London’s in-tray. I truly wish I could say that this is the only example I am aware of in London but it is not. I am afraid that the last Government were rather fond of initiatives that never in practice happened, and of trusting the reports of young consultants at McKinsey rather than those who do the job.
I welcome a world envisioned by the coalition Government where resources are put in the hands of practitioners on the ground with a real understanding of their neighbourhoods and local needs. However, this vision is far from straightforward. Not all GPs will deliver the integrated model of healthcare that I described earlier. Many GPs who support an integrated approach tell me that their colleagues who do not support it fear loss of status and title, without realising that real status in communities is based on the strength of their relationships with patients. Often in deprived areas there is a stark lack of GPs with the capacity to rise to the challenges that they now face. This new approach has important implications for the ways in which doctors are now trained.
The Government need to ensure that GPs are encouraged not to resist change, nor protect an expensive biomedical model of health. We need to show our doctors that an integrated approach to healthcare will address the profound problems that people in disadvantaged areas face, with considerable savings to the public purse. At Bromley by Bow, we run our health centre like any successful customer-focused business. For example, 20 per cent of consultations are conducted on the phone, which saves not only the patient’s time but the GP’s as well. What we all have to realise is that the NHS has access to people across the country which any business would die for. Eighty per cent of consultations in the NHS take place in general practice, and 90 per cent of the population is seen in any one year. If we encourage entrepreneurship in the world of health, then the more capable practitioners will step into these gaps in the market and ensure successful delivery of care.
As the new Government begin to formulate their health policy, I have three questions for the coalition and the Minister, who I wish to thank for a very helpful discussion earlier this week on this subject. First, what is the Government’s vision for the future make-up of primary and community care? Will they simply leave it to the marketplace? Will they promote the standard medical model or the integrated approach of the type I have described? A clear approach is essential for the dedicated medical staff, who have had to suffer countless changes in direction over the last decade and now feel disillusioned, confused and frustrated. Secondly, once the Government have clarified what their future model of primary care and community care will be, how will they deliver and develop this approach effectively? This has simply not been happening. Finally, who in the coalition Government will lead with consistency and longevity, and pursue this course? Under the previous Government, we saw a succession of initiatives and restructuring led by “here today, gone tomorrow” Ministers, which has left the health service, frankly, in ill health. Who will be the leader? That is my key question.
The Government are rightly opening up a world of opportunity and I welcome that. However, the devil, as ever, will be in the detail and perhaps most importantly in consistent leadership not from civil servants but from practitioners—GPs and others who have done the job and understand the practical details on the ground. I encourage the Minister and his Government to lessen their reliance on academics and theorists, who have often never built anything, and to embrace the world of the practitioner and the social entrepreneur; to create a culture where we learn by doing, and not by talking and writing endless expensive documents and papers. We cannot afford this expensive, rather old fashioned way of doing things any more. Let us support—and learn from—people who do the job.
Lord Mawson
My Lords, I have found all the contributions to this debate particularly helpful. In many ways, the issues raised provide the raw material on which we all need to work as we move forward to the next stage of the development of primary and community care. I am only sad that there is not more time to debate some of those issues, but I want to make just a couple of points.
I agree with the noble Baroness, Lady Thornton, about the role of LIFT. In the early days, I tried to persuade GPs and others all over the country to get behind LIFT. It has created a very different kind of world. Indeed, my colleagues in east London won the first £35 million contract and began to demonstrate how it might work. My plea to the Government is that they should stay with LIFT, as I think they will. I suspect that, as a structure, it is achieving only 55 per cent of what could be achieved and that it could do a great deal more, as I pointed out earlier.
Some of the points that I made reflected conversations that I have had with colleagues who run the Big Life Company and with others with whom I am very much in touch. We are all aware that we have come a very long way but that we need to go further. That is the key point.
I thank the noble Earl, Lord Howe, for clarifying some of the issues that I raised. There is a great deal to do, and a lot of practical details that underlie this debate need to be addressed. However, I welcome what I have heard and am certainly willing to play my part in helping some of this thinking to take root.
Finally, if I have any further advice for the Minister, it is the following. First, as I know he is doing, he should decide what his vision for the future of primary and community care is and stick to it. At a time of limited financial resources, I encourage him to embrace the integrated approach to health that I have been describing. It is about more than just the medical profession. Not only does it make good health sense for patients and put flesh on the bones of the concept of the big society at a local level, but it may well enable the Government to get more for less from the limited resources that are now available to them.
Secondly, in deciding their vision, the Government should also take great effort to understand the practical details of how it will work in practice in different contexts within the United Kingdom—particularly in some of our more challenging areas. I very much agree with my noble friend Lady Finlay that we should be careful about unintended consequences. For example, the policy to create free schools, which I welcome, may have real benefits in some affluent areas of the country but may well create social havoc in multicultural areas of London, with which I am very familiar.
Thirdly, the Government should make sure that the people they ask to run these programmes are practical, businesslike people with in-depth experience.
As an entrepreneur, I say that we should back success and let 1,000 flowers bloom. I look forward, together with others, to seeing how the direction of travel develops in the months ahead. In the mean time, I beg leave to withdraw the Motion.
Queen's Speech
Lord Mawson Excerpts(15 years, 9 months ago)
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Lord Mawson
My Lords, I should like to add to the deluge of praise. I congratulate the new Government on their success and wish them well in the coming years as they try to develop a working partnership and deliver their programme. I also want to take this opportunity to wish the Minister, the noble Lord, Lord Hill, well in his new job and to thank new colleagues for four excellent maiden speeches. I also congratulate the noble Earl, Lord Howe, on his new appointment.
As a result of many years of bringing disparate groups of people together to deliver practical results, I know that the key to partnership is to focus on relationships and not just on new structures, processes and strategies. Focus on the relationships and everything will follow. Ignore them and you will face serious difficulties. My colleagues and I have spent more than a quarter of a century bringing together partnerships to modernise public services so that they are more responsive and fit for purpose in our modern enterprise culture.
I thought that it might be helpful if I shared with the new partnership Government a few lessons that my colleagues and I have learnt at the coalface. It might also help them to put some flesh on the bones of what the big society might look like in practice. Many people are wondering what this piece of marketing means. We all know that it is crucial for a new Government to lay solid foundation stones on which real change and development can grow. Real change is elusive and may not come to fruition until a Government have left office. Effective innovation can take a generation and requires committed individuals to champion it. It is rarely captured in a policy document, written by what my colleagues affectionately refer to as “the bright, young things”. Real change has to be grown and deeply rooted in communities, otherwise, as I suspect that new Labour is discovering, it will be blown away like the sand when the first gust of wind comes along.
What are the lessons? How do you create a big society and lift the game in education, health and welfare? First, I would suggest that this Government support organisations that already have a successful record of reforming public services. Do not reinvent the wheel, but build on what works. They should back success and learn from their many years of detailed practical work. Do not, as new Labour so often did, take their best ideas, pass them to the Civil Service machine and exclude these experienced innovators. Let them take the wheel. Support them and enable their efficiency. Do not think that it is now the Government’s job to take control. It is not. They should take the long-term view.
Secondly, we need to question what the overused term “fairness” means. The question to ask is: fairness for whom? If you are seeking to achieve fairness for Karen and her children on housing estates across the country and to improve their educational opportunities or access to health, you must back the best providers with a proven record. It is irrelevant whether they come from public, business, social enterprise or voluntary sectors. However, if you are seeking to be fair in dishing out grants and resources to the voluntary sector, you will do something quite different. Who are you trying to be fair to and why? Life is not fair, and where we began to challenge and question this thinking in east London and embrace not equality but diversity, a thousand flowers began to bloom. “Fair for whom?” is the exam question I leave with the Minister. It is not possible to be fair to everyone.
Thirdly, if fairness is about creating opportunities for employment and improved services, the future must be about enabling environments where business and social entrepreneurs can do business together. These are the new relationships that will reform public services and they are already showing significant success, but this means that some of our cherished ideology will need to be examined and probably dropped. For the last decade, bureaucrats have fed a bureaucracy monster and it is now very large indeed. Often, contracting out has transferred a large government bureaucracy to private sector companies with large contracts—prisons, for example. Then the civil servants have migrated from one large organisation to another. The contracting process seems designed to stifle innovation and risk taking. The role of the new Government needs to be to create a level playing field where new relationships and networks can grow, particularly between business and the social enterprise sector.
Fourthly, I would ask the Minister how he will practically encourage new environments where people “learn by doing”. Will he get his hands dirty by planting the seeds of enterprise in the fertile soil outside the comfortable but dry world of theory? If this new generation of politicians is to gain any understanding of how the real world works in practice, and not hide in the bubble of Westminster, I would humbly suggest that each Member of Parliament should become involved in one project in their constituency to play their part in building the “big society”. Do not pontificate about it: do it. Legislators might then begin to understand the relationship between legislation and practice because attempting to deliver a new school, health centre or service is a practical nightmare nowadays, given the number of contradictory hoops laden with half-baked ideology that practitioners like me have to jump through. The confusion that exists between delivery and democracy is a minefield. The micro is the clue to the macro. Learn from it and gain the public’s respect in the process.
If this Government are serious about empowering communities, Ministers will have to get involved in messy detail. For example, one of the difficulties we face in giving people more professional independence in health is the awkward fact that often doctors do not want to innovate. They have not been trained to think like entrepreneurs and so resist change because they have an entrenched view and an expensive biomedical model of health to protect. This is not just my view, but that of the doctors I have worked with. Can we leave commissioning with doctors? Will they be responsible? It depends on the mindset of the individual doctor.
Finally, the idea that devolving power to local authorities will deliver a plurality of outcomes is not always correct either. Local authorities are not neutral when commissioning services. They often have an aversion to selecting innovative approaches because they do not understand them. Many of their staff have only ever worked in the public sector. They do what they have always done, but change the wording on the forms to please the Government of the day. Look carefully and you will still see the same bodies under new clothes. Local authorities are often the least likely to choose an innovative approach to service delivery, so why are the Government looking to them alone? Could the Minister tell the House what criteria will be used to choose these authorities? How will he select the sheep from the goats? Or, like doctors, are they all as good as each other? Not in my experience.
I wish the Minister well in this time of opportunity. Partnership is a great thing and the present financial crisis is the time to embrace innovation. Never miss the opportunity presented by a good crisis. If you are to deliver, I would humbly suggest that you do not rely on structures or theories, but on people. Back the best people, be they in the business, public or social enterprise sectors, and, funnily enough, you will be fair to everyone.