NHS: London

– in the House of Lords at 7:24 pm on 10th October 2007.

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Photo of Earl Howe Earl Howe Shadow Minister, Health 7:24 pm, 10th October 2007

asked Her Majesty's Government what are the principal challenges facing the National Health Service in London.

My Lords, in asking my Question, I take particular pleasure in welcoming the noble Lord, Lord Darzi, to his place on the Government Front Bench. The noble Lord is known to all of us as one of this country's most distinguished surgeons. Indeed, accolades that pepper his biography bear witness to the extraordinary standing which he enjoys internationally in the field which he has made his own: minimally invasive surgery and, in particular, the development and use of surgical robots. The rich mix of his family roots, which extend from Armenia to Iraq and to Ireland, makes us appreciate how fortunate we are that his feet are now firmly planted in the soil of this country. At St Mary's and at the Royal Marsden, where he currently practises, his contribution to the well-being of patients is pre-eminent, and I have no doubt whatever that his acceptance of the Prime Minister's invitation to serve in a ministerial capacity reflects his desire to make an equivalent contribution to the well-being of the NHS and the nation. May he prosper in that endeavour and may he continue to bring his own very wise perspective to the deliberations of Government.

The Question on the Order Paper is perhaps rather transparently a carrot to lure the noble Lord to this Chamber. Nevertheless, I hope he will agree that a debate on the subject is timely and useful. The report published in July on NHS services in London was very much the product of the noble Lord's careful efforts, and he is to be congratulated on having tackled head-on some extremely difficult issues. The headlines which his report generated were all about the reconfiguration of health provision in London, and a major reconfiguration at that. But in order to understand those proposals, we need to see how the noble Lord got there. His starting point was, if I may venture to say, the right one, and indeed the only possible one; namely, the health needs of London's population. London's population is expanding; it is getting steadily older; it has an unusual ethnic mix; and its health problems are writ large in high rates of drug addiction, sexually transmitted diseases, TB and mental illness. London has some first-rate hospitals and healthcare facilities, but there are parts of the city where healthcare provision is, frankly, inadequate and health inequalities are stark. The east and north of London have sparser GP coverage and sometimes lower funding levels than other areas, yet they have a higher incidence of ill-health. The burden of immigrants in certain parts of the city accentuates many of these problems.

The noble Lord's prescription is therefore to raise London's game and—in a nutshell—to locate the right level of healthcare where it is needed. He is much better placed than I to describe to your Lordships what each level will look like: specialist and major acute hospitals handling more complex care; polyclinics for community-based services; local hospitals with a redefined role; and elective treatment centres. I have no doubt that he will wish to flesh out his vision for these different tiers of service. But the purpose of such a reconfiguration is not in dispute: it is to improve the quality of care delivered by the NHS across the board and to focus also on prevention and health promotion, which in many areas of the capital receive scant emphasis. Those aims are to be thoroughly applauded.

It is the implications of some of these proposals which the noble Lord will know have been exercising the healthcare community since his report was published. Perhaps their most obvious implication is that they would lead to radically new ways of working for many professionals, especially consultants. Staff, including GPs and nurses but also, particularly, the London Ambulance Service, will need to acquire different skills. These things would be necessary and far from insurmountable, subject to sorting out issues relating to the transfer of employment. But some of the other implications are perhaps more problematic.

There are several that have loomed large. The first is how we get from A to B. The road map to implementation is not yet clear. The creation of a double running fund to allow new facilities to be created while the old are still in operation poses considerable financial questions, and it would be helpful to hear from the noble Lord what the up-front investment is likely to be.

The second concern I have relates to the financial savings that are posited from the new arrangements. These are given as £1.5 billion a year, but again it is not self-evident to me how such large savings might arise, bearing in mind that the delivery of care by a polyclinic is unlikely to be less expensive than the delivery of care by GPs and a district general hospital. I worry too about the continuing viability of PFI hospitals which currently depend on revenue streams that would be removed from them under the proposed arrangements. If these hospitals are not to close—and the fear is that some might have to—has enough work been done to test alternative budgetary models?

No one can object to the idea of setting up a polyclinic in an area where family doctor services are weak and community access is difficult. But what is seen to be the benefit of shutting down hundreds of GP surgeries where primary care is being delivered to a good standard? Doing so may well involve longer distances for patients to travel in order to access primary care. And if the services provided in a particular district general hospital are viable, successful and accessible, is there really a compelling case for shipping those services out to a different location?

There are perhaps two areas of hospital care where special concern arises. The first of those is maternity services. The noble Lord has rightly focused on maximising choice for expectant mothers, but he has also worked on the assumption of a smaller number of obstetric units with a relatively high level of consultant presence on each of them, and at the same time a larger number of midwife-led units than at present. The difficulty here is the lack of an evidence base in relation to patient safety. Quite frequently, women who are about to give birth in a midwifery unit need to be transferred to the care of an obstetrician. Exactly what is a safe distance between a midwife-led unit and a consultant-led unit? How are we to decide—and indeed who will decide—on the location and staffing levels of both types of unit, and on what research data will they base those decisions? The background here is not only a shortage of midwives in London but also a rising birth rate, and it will clearly be essential to have a configuration of services that is reasonably future-proof.

The second main area of concern is accident and emergency. Under the noble Lord's proposals there would be more urgent care centres but fewer full A&E departments. The question, once again, is about the evidence base for this model. Although urgent care centres are likely to be called "A&E", they will lack intensive care beds, and it is that which will govern outcomes in a significant number of cases. Of course, ambulance crews would be trained to take a patient to the hospital with the right level of care, but there are a number of medical emergencies—for example, where someone is having breathing difficulties—where the distance the patient has to travel has a direct bearing on that person's chances of survival. The downgrading of district general hospitals from being able to provide full accident and emergency cover needs to be justified by the most rigorous research. It is interesting that the Academy of Medical Royal Colleges, if it has been reported correctly, maintains that most district general hospitals should be able to provide full A&E, even if in some specialties they lack critical mass in terms of patient numbers.

In raising these issues, I do not want the Minister to think that I am pouring cold water on ideas that are clearly the product of intensive consultation. I have the highest respect for him, and am more than ready to be convinced. However, it seems that work still needs to be done on some of the feasibility aspects. It would be helpful to know whether the recommendations in his report represent official government policy. If they are ultimately to succeed, it is essential that patient groups and healthcare professionals—not least the GPs—should feel a sense of ownership of the changes. To that end, there may well be a case for piloting the polyclinic model in one or two areas to demonstrate how it could be made to work.

I hope the Minister will take my questions in the constructive spirit in which they are meant and look I forward very much to hearing his reply.

Photo of Lord Warner Lord Warner Labour 7:35 pm, 10th October 2007

My Lords, I welcome the noble Earl's decision to have a debate on this important issue, and I congratulate him on the constructive way he has approached the subject today. It is important that we are able to have honest and open debates about this difficult set of challenges in a major urban complex.

I welcome the opportunity this gives me to congratulate my noble friend Lord Darzi both on his appointment as a health Minister—we may end up commiserating with him at a later date, from my personal experience, but at this moment, in the flush of newness, I congratulate him—and on the report he has produced. I want to mention the inclusive way in which he went about producing it, bringing in a range of opinions. I observe also that he is going about the wider review that he is conducting in exactly the same way. Many will appreciate the inclusive way in which he is going about his work.

I have to declare an interest. For the past six months I have been the part-time chairman of a new body set up by the London Strategic Health Authority called the Provider Agency, operating from the SHA but in a more arm's-length way on a day-to-day basis. It is concerned with the performance and development of those acute and mental health trusts that are not yet foundation trusts and helping them to achieve FT status. We have recently taken on a similar development in relation to PCT provider services, and are currently engaged with tackling the problems of the eight "financially challenged"—as they are euphemistically called—acute trusts in London. Some of those problems are very longstanding and go back many years. In tackling them, we will be drawing on the valuable contribution made by my noble friend Lord Darzi in his framework report.

So I am right in the middle of the challenges faced by London's NHS. Many of these issues not only go back in time but are also complex, often having at their heart a reluctance to tackle difficult clinical, organisational and—dare I say it?—political problems. The noble Earl will perhaps be relieved, or perhaps not, to know that I am going to behave in a non-partisan way today. I do not claim that this mood will last forever, but so far as today is concerned there is probably a large measure of agreement about the kinds of problems that have to be tackled in London. As the noble Earl said, a lot of it is about how we go about tackling those issues.

My noble friend made a major contribution with the document he published earlier in the year, setting out some of the causes that make it necessary for us to engage with change. I shall pick out just one of his eight reasons: the health inequality issues, which the noble Earl drew upon. We all know that if you travel down the Jubilee Line from Westminster to Canning Town, you will find at the end of that journey that the life expectancy at Canning Town is seven years less than that at Westminster. That is a major issue for London. One of the issues we have to grapple with now is how we transfer resources to the parts of London that are less well provided for from those that have strong resources.

I do not have much time left. I offer two thoughts. First, we have to tackle the weakness of community services in many of our deprived areas, and we need to bring in a richer mix of providers to do that. Secondly, we have to consider how we use land, buildings and equipment in London, which has some of the most expensive real estate in the country, and use those resources more efficiently and effectively to help deliver some of the vision in my noble friend's report.

Photo of Baroness Masham of Ilton Baroness Masham of Ilton Crossbench 7:40 pm, 10th October 2007

My Lords, I thank the noble Earl, Lord Howe, for giving us a chance to welcome the noble Lord, Lord Darzi of Denham, to your Lordships' House as Minister responsible for health. As a leading and dedicated professor of surgery, the Minister may find it difficult to comprehend the many challenges that face the NHS as there are so many different principles.

London, with its diverse communities, has become a huge challenge to the NHS. The scourge of drug and alcohol abuse and the increasing incidence of gunshot and stabbing injuries increase pressure on it. My heart goes out to the family of the Polish care worker who was killed in crossfire last week.

A priority in patient care should be the quick release of results of tests and scans, correct diagnosis and the most appropriate treatment. That would lessen the risk of long-term disability, as was illustrated to me on a visit to King's College Hospital.

As president of the Spinal Injuries Association, I have seen many disasters occur when patients with injuries to the neck and back, which can lead to paralysis, are not treated in a specialist spinal unit. Accidents happen in so many different ways. A young electrician in Westminster who fell through a skylight landed on a spike which pierced his liver and severed his spinal cord. Once his liver was repaired, he was transferred to Stoke Mandeville Hospital for spinal treatment. The priorities are the treatment of bladder and bowels and the prevention of pressure sores. General hospitals in London lack the routines required and the trained staff.

On a visit to Lambeth Walk health centre, I found excellent fast-track testing for HIV, with the results available in a few hours, counselling if the results are positive and referrals to specialists. However, numbers of health visitors and community midwives have been cut, which is worrying in a deprived area.

So much could be said. Does the Minister know that many London hospitals, of which Chelsea and Westminster is a good example, are helped by valuable volunteers? However, no centrally collected data on volunteering are available in the NHS. If the Healthcare Commission asked trusts how many volunteers they had and what roles they played, it would be very useful.

I hope that the Minister will take up the challenge of improving prison health, which is now the responsibility of the NHS. Many large prisons in the London area have inmates who have mental health problems or abuse drugs. They have seen an increase in blood-borne viruses, tuberculosis and sexually transmitted diseases. Health staff in prisons need all the support they can get. I wish the Minister every success in his new position. I was going to say many things this evening, but due to the limited time available, I decided to write to the Minister about them. One of the issues that I intended to raise is patients who, having been transferred to a hospital specialist, have to be transferred back to the GP and then back to a hospital again if they need to see a further specialist. I hope that the Minister will be able to do something about that. We are delighted to have him here.

A

May I add to the comments of the Hon.Lady the need for a speedier diagnostic technique for mental illness. Scanning techniques are now available, and would hasten the treatment of these unfortunate patients, probably by speedier and more efficient prescribing of medications.

Submitted by Alix Cull

Photo of Lord Winston Lord Winston Labour 7:44 pm, 10th October 2007

My Lords, I congratulate the noble Earl, Lord Howe, on ably introducing this important debate with his usual words of wisdom and care, which are much appreciated in the House. It is good to see my noble friend and, if I may say it, colleague on the Front Bench. That he is a colleague from Imperial College is apt to my declaring my interest in this debate. His presence here is very good news, and I hope that he will be able to improve our health service in due course.

His report is full of aspiration, which is to be commended. However, the inequalities in health care in London will not be solved by the NHS. As we well know as medics, those inequalities are solved mostly by changes in the environment, by alleviation of poverty, by better education and, to some extent, prevention of disease, on which the report focuses.

I do not have time to talk about much of what is in the report. I am a little concerned about obstetrics. Only in the past week, two opposing positions on the value or safety of home delivery have been argued in the British Medical Journal. There is no clearly stated evidence yet that it is truly safe. The health service faces massive legal costs for babies which are seen by the courts to be damaged. I am concerned also that continuity of care may not be offered to obstetric patients who may be treated first for their gynaecological condition or their fertility problem and have to go to different health authorities for their treatment. That is certainly a problem at Hammersmith, where I used to work.

I am concerned, too, by mental healthcare. A key issue in London on which the report does not focus is the environment for mental health patients who are inpatients. It is desperately depressing to visit a mental health ward. Many patients are probably made worse by that environment.

As the report states, London is a major city: it is one of the great cities of the world. It is also one of the greatest cities, unparalleled in Europe, for medical education. It is an extraordinary centre for research, teaching and training. Imperial College is probably the biggest medical school in Europe, and it is highly successful. We have University College, King's College, Queen Mary College and St George's at Tooting—it is an extraordinary line-up. We must recognise in London the failure to translate much of the research that takes place from the basic area. It needs to be much more focused in the future if we are to go forward with healthcare. The report had trouble mentioning translating research; it mentions MRI and penicillin. Huge gaps need to be addressed.

There is a crisis in the confidence of people going into academic medicine, which is severely threatened. Listening to this debate is a medical student from Imperial College who, like so many of her colleagues, is thinking of doing her PhD not in London, but in the United States, because she is so disenchanted by her prospects.

We might be well advised to consider bringing back the old method of training junior hospital doctors. Perhaps my noble friend will think about it. The FIRM system had a lot to recommend it. I understand that appointments to it were likely to be biased and subject to misplacement, but it would be unwise to give up completely the advantage of working in a unit where doctors covered for each other and had a team responsibility. It was deeply important when I was training, and it still is.

Photo of Lord Colwyn Lord Colwyn Conservative 7:49 pm, 10th October 2007

My Lords, I thank my noble friend for initiating this debate and welcome the noble Lord, Lord Darzi, to his position on the Front Bench. In the few minutes available to me, I ask the Minister to consider the provision of dental services in London and the rest of the country. I remind him of Prime Minister Blair's pledge in 1999 that, by September 2001, everyone would have access to an NHS dentist, no matter where they lived. Seven years later, fewer than half of British adults are registered with an NHS dentist.

The introduction of the new contract in 2006 gave primary care trusts responsibility for commissioning NHS dental services using a fixed budget set by central government. The new contract was introduced to improve access to NHS dentistry, but a recent survey of NHS dentists has shown that only one in five dentists is taking new NHS patients; four out of five restrict access to NHS treatment in some way; 80 per cent say that no new treatment capacity is available in their area; and half of all dentists are having problems meeting their NHS output targets and face financial penalties. Forty percent of dentists would like to leave the NHS; 95 per cent were less confident in the future of the NHS than two years ago; 93 per cent of dentists believe that the new contract has done nothing to boost a more preventive approach; and 97 per cent believe that the new contract has failed to get them off the treadmill. A year after the introduction of the new contract, fewer patients are able to access an NHS dentist, fewer dentists are providing NHS care and nearly 400 contracts are still in dispute.

In the 24 months up to December 2007, 51.6 per cent of the population of London strategic health authority saw an NHS dentist, compared to 55.7 per cent nationally. Uptake in London is higher among children and in this period 65.3 per cent of children visited an NHS dentist compared to 47.8 per cent of adults. This compares poorly with the national average where, in England, 70.5 per cent of children and 51.5 per cent of adults visited an NHS dentist. There is a variation in uptake across the capital, the highest being Hounslow, where 69.4 per cent saw an NHS dentist and the lowest being Kensington and Chelsea, where just 21.6 per cent saw an NHS dentist. There are 50 dentists per 100,000 population in London compared to a national average of 41 dentists per 100,000 in the rest of the country.

I have carefully read the Minister's recent reports: A Framework for Action, published in July, and, last week Our NHS, Our Future. The Minister is a doctor, not a politician, so in his new position I am sure that he will have been looking for some practical answers to the serious problems in the dental services and the difficulty of access to an NHS dentist. In his summary letter to the Prime Minister, he said:

"My aim is to convince and inspire everyone working in the NHS, and in partner organisations, to embrace and lead change... I have spent the last three months visiting different NHS organisations and hearing the views of staff. This report is based on those views, visits and discussions".

That is very commendable, but then I find that in the 133 pages of A Framework for Action and the 54 pages of Our NHS, Our Future, I cannot find a single word—not a single reference—to any part of the dental service. The clinical working group membership lists 124 medical specialists and advisers—not a single dental expert or dental viewpoint. There are about 120,000 people working in NHS dentistry, including nurses, receptionists, practice managers and technicians. Do they not deserve any recognition or representation, or planning for their future? Are the Government planning to remove dental treatment from the NHS?

I shall look forward to future debates with the Minister. He will be a great asset. But in this House his remit includes dentistry, and I am not going to let him forget it.

Photo of Lord Rea Lord Rea Labour 7:52 pm, 10th October 2007

My Lords, I am very grateful to the noble Earl for giving us this opportunity to explore my noble friend's framework for London and giving him a chance in his maiden speech, to which we all look forward, to defend his plan.

Of the 45 years that I spent as a student and practising doctor, 39 were in London and 25 of those as a GP in a health centre, so I am only too well aware of London's health problems. The 122 members of my noble friend's working groups, of which 57 were clinicians and 10 GPs, have outlined London's problems clearly, particularly in recognising the existence of widespread areas of social deprivation, with poorer health and greater healthcare needs. But I am not sure they have sufficiently emphasised the extent of these extra needs in populations with higher than average proportions; for example, of asylum seekers with linguistic difficulties, high levels of drug and alcohol abuse, acute housing problems and social breakdown. As my noble friend Lord Winston said, most of those problems are well outside the reach of the health service.

In my three remaining minutes I shall speak about primary care and the proposed polyclinics. The term suggests to many people a rather impersonal form of care. In fact, one of the main concerns of the BMA and many others is that the much-valued doctor-patient relationship will be damaged in a polyclinic setting. This view was expressed vividly by Dr Iona Heath, a former colleague, in a recent BMJ article, The Blind leading the Blind. Apart from provocatively asking why a tertiary care specialist should be redesigning primary care, she questions whether a polyclinic is the right setting for a patient with complex medico-social problems, for example, who may be intimidated by a large institution. If polyclinics—or whatever name they are finally given—are going to be built, it is important that they are designed in a patient-friendly style. It makes economic sense to unravel and deal with patients with multiple problems at a local level rather than letting them bring their multiple symptoms to block A&E departments.

My noble friend Lord Darzi is not the first eminent specialist to tackle primary care. In 1920, Lord Dawson of Penn, a highly respected physician, produced a report on the future provision of medical and allied services. A network of primary health centres was to be set up, linked to secondary health centres—hospitals—in turn linked where possible to teaching hospitals. The primary health centres would be run by GPs, who would have at their disposal on site radiology, bacteriology, biochemistry, electro-therapeutics—which I take to mean physiotherapy in today's terms—and assistance from visiting consultants, specialists, nurses and health visitors.

The polyclinics in the current plan would have all those features and more. Some might say that the Darzi plan is the Dawson plan brought up to date. Sadly, the Dawson plan never reached fruition; it was too ahead of its time and Lord Dawson did not have any power to apply it. However, the Prime Minister has given my noble friend, in contrast to Lord Dawson, the position—and yesterday, the Chancellor, the funds—to implement his plan. I hope that he does so wisely and tactfully, easing forward incrementally, a little at a time rather than introducing yet another administrative upheaval. He has made a good start by including a substantial number of clinicians and other healthcare professionals, who know the problems involved when drawing up the plan. He has promised to continue to be in touch with professional colleagues in the next stages, and to do so will increase his chances of success.

Photo of Baroness Emerton Baroness Emerton Crossbench 7:57 pm, 10th October 2007

My Lords, I thank the noble Earl, Lord Howe, for raising this short debate on the very important subject of the challenges facing the NHS, and I join in his congratulations to the noble Lord, Lord Darzi, on an excellent report which reflects the enormous amount of work undertaken in the past months.

Changes in the delivery of healthcare inevitably bring changes in the roles of those delivering the care, and one of the greatest challenges is to provide the right number in the right place at the right time with the necessary knowledge and appropriate skills. I declare my background as a retired nurse. The nursing and midwifery professions have the largest single numbers of employees within the NHS, and it is vital that nurses and midwives are care-efficient and cost-effective.

It is pleasing to note that work is already under way in reviewing the workforce implications of the proposals, including the education and training to be required. However, it is crucial that the universities are fully involved with strategic health authorities from the beginning and not merely consulted when preliminary conclusions have been reached. Indeed, it is vital that non-medical deans in the universities and the Council of Deans are involved. These are the people with expert knowledge of the educational, training and research needs. However, it will also be difficult to provide for the workforce plans without agreement on the service reconfiguration. So timing is a real challenge. This review provides the opportunity, too, to repair the damage of the last two years, when the infrastructure in many universities suffered due to the diversion of funds by SHAs to rectify the NHS deficits.

Recent research forecasts that 150,000 nurses and midwives will retire in the next 10 years. Any disruption to the education and training programmes has a long-term effect not only because of the length of the training but also because of the number of institutions engaged in pre- and post-registration programmes. Paragraph 48 of the report Making the Vision a Reality recommends a rationalisation of training institutions. That will need very careful consideration and understanding of the complex interface and relationships of placements for students, as the numbers seeking placement are greater than the number of placements in the medical profession.

Will the Minister ensure that nurses and midwives with skills in workforce planning are engaged, with the appropriate knowledge and understanding of the different clinical pathways required for all the different specialities? This will ensure that the knowledge and skills requirements are fully met so that high-quality and cost-effective care is delivered to patients.

Workforce planning is related not just to numbers with the appropriate knowledge and skills base but to the accountability and authority vested in each role. The Burdett Nursing Trust sponsored a study resulting in a report published last November, Who Cares WinsLeadership and the Business of Caring, which could perhaps be simply described as accountability from the bed to the board. The report clearly makes the case for an executive director at board level who is accountable for the performance management of clinical care. When modern matrons were introduced, many of them had no professional accountability to a nurse but only to a non-healthcare professional. The recent announcement of more modern matrons to combat the hospital-acquired infections MRSA and C. difficile will be to no avail unless authority and accountability is built into the role from the delivery of care through to the board.

Achieving these changes raises what I consider to be the largest challenge facing any of the recommendations for change: the need for a complete culture change throughout the NHS, beginning at board level, whereby the balance between finance and care is restored instead of the current distortion in most NHS boards whereby the emphasis is on finance and targets with little evidence of patient-care delivery being an agenda item. No business can succeed unless there is customer satisfaction. This week's Healthcare Commission report on complaints speaks for itself.

Will the Minister reassure us that, within the implementation programmes, workforce planning, authority, accountability and culture change will be addressed so that the NHS may once again be recognised for high standards of healthcare delivered with care and compassion?

Photo of Lord Haskel Lord Haskel Labour 8:02 pm, 10th October 2007

My Lords, I add my thanks to the noble Earl, Lord Howe, and extend a warm welcome to my noble friend Lord Darzi. The main thing that I wish him is stamina. Being on the Front Bench and doing a job outside Parliament will require lots of it and I wish him every success.

This is not the first report on health services in London; my noble friend Lord Turnberg wrote one in 1998, and indeed the report of my noble friend Lord Darzi refers to it. My noble friend Lord Turnberg would like to have spoken this evening but was unable to do so because of a prior engagement. However, he and I discussed this report on healthcare in London. We agreed that by addressing people's needs so directly it certainly moves the NHS in London forward. We welcome its progressive change and its proposals will ensure that the money budgeted for primary care in yesterday's Pre-Budget Report will certainly be well spent.

Our concerns lay not with the ideas, most of which deserve support, but, as other noble Lords said, with some of the practicalities. For instance, the sequence of change is important. The noble Earl, Lord Howe, was also concerned about that. Great care will have to be taken to ensure that hospital services in London are not cut in advance of the increase in care provided by the clinics and enhanced GP services. Surely these services will have to be built up first. If they are not, there will initially be a fall in service provision.

Another practical concern is the calculation of the population requiring care. The report certainly attempts to provide for tourists, business and professional visitors and students, but what about the huge transient population of casual workers who stay here for 18 months or two to three years, many of whom are from the new member states of eastern Europe, with many living in the poor conditions that my noble friends Lord Winston and Lord Rea described? Underestimating this demand will result in a fall in service provision for everybody. This is why the population estimate will have to be generous.

Another practical consideration is the need to break down the current divide between primary care and hospital care. Surely it makes sense to get GPs and hospital specialists together to agree how care is best provided, by whom and to what standard. Surely this is the only basis on which contracts can be drawn up. An example of the problems caused by this failure to integrate can be seen in the maternity services to which other noble Lords referred. The damaging divisions between obstetrics, midwives and GPs have caused many difficulties. I agree with other noble Lords that patients need to be assured that they are receiving the best care for them as an individual and their baby and are not subject to the biased views of one part of the service.

However, apart from these practical considerations my noble friend presents a compelling vision for the future of health services in London. Like my noble friend Lord Winston and others I welcome its vision and aspirations. It certainly deserves our support.

Photo of Baroness Barker Baroness Barker Spokesperson in the Lords, Health 8:06 pm, 10th October 2007

My Lords, on behalf of my colleagues on these Benches I too extend a very warm welcome to the noble Lord, Lord Darzi. To have in this place someone of his experience and outstanding achievement will be immensely valuable. We very much look forward to working with him. The noble Lord is renowned as a surgeon for his ability to develop minimally invasive techniques which achieve radical improvement while minimising disruption and damage. If he can apply that approach to the structure and management of the NHS, I am sure that he will command widespread support and respect.

I also congratulate the noble Earl, Lord Howe, on initiating this debate because London faces an increasingly complex number of health challenges. Some—for example high incidences of HIV, substance misuse and mental health problems—are perhaps inevitable where there is a highly diverse and mobile population. Others, such as the disparities in access to GP services, arise in part from the historical complexity of the NHS itself.

Following yesterday's CSR announcement, we know that the NHS in London will face two additional challenges. The increase in NHS funding for the next three years will be 3.2 per cent, not the 4.4 per cent which Sir Derek Wanless stated is needed to meet the demands that his report analysed in great detail. Furthermore, the increase of only 1 per cent in funding for social care via local authorities will mean that a reduction of care services will lead to those with high dependency turning increasingly to the NHS.

The framework for action of the noble Lord, Lord Darzi, has much to commend it, not least the level of engagement by clinicians, which all too often has been lacking in many recent government initiatives. However, the report's main strength is that it sets out a clear pathway into acute and specialist care for people with identified clinical needs. That said, I echo the comment of the noble Lord, Lord Rea, that GPs have reacted to the report with a lack of enthusiasm for the further shift of diagnostics into the community. That is somewhat surprising. It seems that they are yet to be convinced that the diagnostic shift will lead to an overall improvement in clinical pathways. I am sure that the noble Lord agrees that getting GPs on board with his plan is integral to its success. I would be interested to know how he intends to do that.

It is difficult to tell from the report how it will work in practice because much of the detail and costings are not there. I should like to know at some stage from the Minister how far his plans are realisable within the existing tariff system and what the system of payment by results will mean in terms of his ambitions being realised. Like the noble Lord, Lord Winston, I agree that the report is deficient in that it does not address mental health issues. That is a key issue in London for people of all age groups. I am sure that the noble Lord has taken that on board by now and will address it when he rolls out his plans across the rest of the United Kingdom.

Yesterday, the Government announced a Green Paper on the future of social care. That is very much welcomed by these Benches because it is only by addressing how we support an ageing society with people with long-term care needs that we will be fully able to assess the environment in which the plans of the noble Lord, Lord Darzi, will have to be implemented. That is important, as we have said many times in your Lordships' House.

Finally, the implementation of this plan must depend on having a world-class IT system that enables patients to move smoothly between establishments and one in which clinicians have confidence. Does the noble Lord believe that the requisite IT support will be in place? This is an ambitious plan. Like the noble Earl, Lord Howe, we wish to be convinced of its viability. I wish the noble Lord all the very best with his attempts to get it to reality.

Photo of Lord Darzi of Denham Lord Darzi of Denham Parliamentary Under-Secretary, Department of Health, Parliamentary Under-Secretary (Department of Health) 8:11 pm, 10th October 2007

My Lords, I begin by congratulating the noble Earl, Lord Howe, on securing today's debate on a subject that, I am sure he knows, is dear to my heart. I have worked in the NHS in London for 17 years and I am continuing to do so, as well as working in my new role as a government Minister. I owe it to the House to explain my ministerial role. I will be working as a government Minister for three days a week and operating on patients for two days a week. As most noble Lords know, I could not put down my scalpel just yet, as the desire to care for patients and to improve quality of care were the two reasons why I came into medicine in the first place.

My government role gives me the opportunity to ensure that those values of high-quality, evidence-based and patient-centred care will be accepted by all—clinicians, politicians and policy-makers—as the central principles for the reformed NHS. That is what is driving me in my review of the NHS. I will be holding regular meetings open to all noble Lords on the progress of my review, which will also, I hope, allow me to benefit from their sage advice, some of which I received today from the noble Lord, Lord Colwyn.

For those noble Lords who have been listening with interest to the Report stage of the Local Government and Public Involvement in Health Bill, I emphasise my strong belief in the importance of listening to patients, public and staff. I have already spent three months doing just that in the first stage of my national review, culminating in last week's interim report. I will continue to listen over the next few months in the review's second stage.

I first took this consultative approach in my work on London, where 150 clinicians and 200 members of the public were directly involved, while thousands more gave their views in surveys and representations. What I heard led me to identify eight reasons why healthcare in London needed to change—eight challenges that need to be addressed. I do not have time to mention all of them here, and I commend my report to the House for a more in-depth consideration of the issues; a copy has been placed in the Library. Instead, let me focus on three of them: inequalities, outdated healthcare provision and public demands. Those challenges are not unique to London, but they are particularly acute in the capital and require solutions specific to a large urban area.

As the noble Earl, Lord Howe, eloquently described, London has both the best healthcare and the worst healthcare in England. Some of London's hospitals are international leaders, while unfortunately others do not meet the expectations that we all try for. Meanwhile, the fewest GPs are found in the areas with the greatest needs, such as north-east London. Those inequalities in care are matched by inequalities in outcome, as highlighted by my noble friend Lord Warner. As he described eloquently, the journey between Westminster and Canning Town on the Jubilee Line is just eight stops, 20 minutes, a distance of six miles and a cost of £2. But the average life expectancy is seven years lower in Canning Town than in Westminster. Another example is that the infant mortality rate in Haringey is three times that in Richmond.

Equality was one of the founding principles of the NHS. As we approach the 60th anniversary of the NHS, it is a noble principle to which we must return. I have made suggestions in my report as to how I think this can be achieved, including by encouraging the best hospitals to provide services on other sites. For instance, why can we not have the excellent cancer care provided by the Royal Marsden at other London hospitals? However, a lot of London's health inequalities can be tackled only if the NHS ensures that people stay well, rather than simply seeking to patch them up when they are ill. Improving health must therefore be part of the core business of the NHS rather than an optional extra. I am confident that the NHS will be supported in this by other public services. The Mayor of London took a considerable interest in my report and he is using its recommendations in his overall health inequalities strategy for the capital.

While we strive to reduce inequalities for Londoners, we must increase inequalities between hospitals. By that, I mean that we cannot have 31 hospitals all providing the same services. That is not a revelation. When Bevan spoke in the other place to advocate the Bill to establish the National Health Service, he noted:

"Two hospitals close together often try to provide the same specialist services unnecessarily".

Yet 60 years on, that outdated model of provision persists in London.

Stroke care is an example. Currently, 31 hospitals are providing stroke care, most of them badly. When I started my London work, we had the 2004 data that showed that stroke care was poor. All the clinical colleagues whom I met told me that the data were old and that things had improved. Then the 2006 data were published and the figures were significantly worse. That is because providing acute stroke care at all hospitals is outdated. It was fine in the past; when I was training, stroke treatment used to consist solely of rehab, so it did not matter which hospital a stroke patient went to. However, it is now possible to intervene and to treat strokes with thrombolytic drugs—so-called clot-busting drugs—following a rapid CT scan. Such treatment cannot be provided in all hospitals but should instead be concentrated in a smaller number providing acute stroke care to the highest international standards.

That is why my report is not about the closure of hospitals, but rather seeks to make a clearer distinction between types of hospitals. There is a need to clarify which hospitals should be providing the most specialist care to the victims of serious car accidents—as highlighted by the noble Baroness, Lady Masham—or the sufferers of a major heart or brain attack. Those should be separate from those dealing with the less critically ill. Any other approach would be detrimental to patient care. That is why I said in my London report:

"The days of the district general hospital seeking to provideall servicesto ahigh enough standard are over".

For reasons that are beyond me as a humble clinician, most of that sentence is removed when it is quoted.

I come back to the very important point raised by my noble friend Lord Winston. Our healthcare provision also lags behind our international comparators in co-operation between academia and healthcare. Countries such as Switzerland and Canada have established academic health science centres—partnerships between leading hospitals and universities. They help to ensure that new healthcare innovations are transferred rapidly into improved patient care. I hope that the academic health science centre that I recommended, which is now being established by Imperial College, St Mary's Hospital and Hammersmith Hospital Trust, will be followed by other centres of excellence across the country.

My noble friend Lord Haskel raised an important point about the division between primary and secondary care; it is another good example of outdated healthcare provision. There is a chasm between the one- or two-handed GP surgeries that make up the majority of London's primary care practices and the capital's hospitals. That is why I proposed in my report the creation of polyclinics. These community health facilities will provide more services, more locally. Polyclinics exist across the world, from Switzerland to Singapore, in America and Australia, so they are tried and tested. They can also provide the sufficient scale for the shifting of care closer to home that the Government envisaged in the Our Health, Our Care, Our Say White Paper. Polyclinics were also anticipated back when the NHS was established. Bevan talked about the importance of health centres with dental, maternity and diagnostic services on site. He even expected the infrastructure to be available for local specialist services, saying that,

"specialist services, therefore, will not only be available at the hospitals, but will be at the back of the general practitioner should he need them".

My noble friend Lord Rea argued that polyclinics may depersonalise primary care and that patients will lose a personal relationship with their doctors. I say that there is no reason why this should happen. I work in a large hospital with hundreds of doctors. I still get to see my patients on a one-to-one basis.

People, especially those with ongoing long-term conditions, including mental health conditions, should be able to see a regular doctor at a polyclinic. But as well as receiving that continuity of care, they will be able to have diagnostic tests on site, have a dental check-up, discuss their care plan with their social worker and perhaps even have a meal in the polyclinic's healthy café. Polyclinics are a viable answer to London's healthcare challenges and I expect them to develop locally. Those suggesting that I envisage the herding of GPs into polyclinics imposed from above have missed the whole tenor of my report, which is about ensuring that change is led from the bottom up by local clinicians. Indeed, the Royal College of General Practitioners called on its members to seize the opportunity offered in my report to develop new federated models of polyclinics.

Such new provision must move beyond a nine-to-five culture. Why in a 24-hour city is most healthcare only available for a third of the time? Twenty-first-century Londoners expect services to fit around their needs in a flexible way, but the NHS has remained in the 20th century in the levels of convenience and customer service that it provides. Studies have shown that, despite great improvements in healthcare, from 1983 to 2003 satisfaction with the NHS fell, as people's expectations rose. For the pre-war generation the very existence of a health service offering care free at the point of need was a thing of wonder. Those who have always known an NHS rightly expect far more from it, and if the NHS is to maintain public support and last another 60 years, it has to meet these expectations—expectations that include convenience. That means not always having to take time off work for doctor's appointments. It means having more community-based and midwife-led services, which people told me they wanted to see in London. It means a big expansion of local urgent care facilities, not a closure of accident and emergency departments. Most of all, people expect to be treated as an individual with their particular personal needs met. So, instead of a one-size-fits-all health service, we need one tailored to the individual's needs, whether that is a child with asthma or a cancer patient at the end of their life.

Perhaps I may come back to the important point on workforce planning raised by the noble Baroness, Lady Emerton. I could not agree more. One of my recommendations to the health authority was not only to design the workforce, but to design it in a way that meets service needs.

To conclude, it is clear that inequality, outdated healthcare provision and public demands are three big challenges. But we can overcome those. I have offered some suggestions in my maiden speech as to how they can be addressed. I remind the House that I did this piece of work as a clinician and I am very much looking forward to my noble friend Lord Warner implementing some of the recommendations of the strategic framework.

I believe that NHS London, as the single strategic health authority for the capital, is ideally placed to take forward the recommendations in the Health Care for London report. It will take them forward with clinicians, managers, local authorities, other partners and—most important of all—the people of London. I believe that the result will be the world-class healthcare that Londoners deserve.

Photo of Earl Howe Earl Howe Shadow Minister, Health 8:25 pm, 10th October 2007

My Lords, I congratulate the Minister on behalf of the whole House for a truly excellent and most authoritative maiden speech. To give a maiden speech from the government Dispatch Box is not everyone's idea of a gentle baptism, but the noble Lord starts his parliamentary life with two associated advantages: first, the fact that he is without question master of his subject; and, secondly, the respect and good will with which he is regarded by noble Lords on all sides of the Chamber. I have already adverted to the Government's good fortune in having the noble Lord in their midst, but the good fortune is ours as well. While we are bound to appreciate the considerable calls on his time in the next few months at least, I believe, in the light of his speech today, that it is not wrong of me to express the hope that we may look forward to his addressing us on many more occasions in the future.