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Health: Primary and Community Care — Debate

– in the House of Lords at 2:39 pm on 24th June 2010.

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Moved By 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.

Photo of Lord Mawson Lord Mawson Crossbench 2:41 pm, 24th June 2010

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.

Photo of Lord Colwyn Lord Colwyn Deputy Chairman of Committees 2:56 pm, 24th June 2010

My Lords, I congratulate the noble Lord, Lord Mawson, on securing this debate. I listened to his speech with great interest. He has a splendid vision for future healthcare and should be congratulated on all that he has done. I hope he will forgive me for not following directly his line of thought. I am not used to speaking so early in a debate; normally every subject has been covered by the time I get to my feet. I must concentrate on matters that have affected and will affect my dental colleagues. I have no need to declare an interest. I was in dental practice for more than 40 years but I have now been retired for two or three years.

As I said in the debate on the Queen's Speech, the past 10 years have seen fundamental changes to the provision of dental services. We have been left with unfinished reform of NHS dentistry and must now work to deliver a better system both for patients and dentists, even at this time when the Government are making complex financial decisions which will affect us all. Alongside the challenges of oral health promotion and NHS dentistry, general dental practitioners face mounting challenges in the management of their practices. The creation of the Care Quality Commission, with which both NHS and private practices must be registered by the end of March next year, imposes a further layer of regulation on dental practices.

Why this current explosion in the evaluation, accreditation and remediation of health professionals? The CQC emphasis is on the registration and inspection of practices, rather than the assessment of individual performance. This will probably be followed by the General Dental Council's proposed revalidation processes, focusing on individual registrants rather than the environment in which they happen to be working. There will be areas of overlap, which will need to be looked at to avoid duplication and possible misinterpretation.

The British Dental Association's Good Practice Scheme recognises the practice, not the individuals within it, and Denplan Excel has, for nearly a decade, been independently auditing dentists against a full range of quality and oral health measures, regularly visiting the practices and de-accrediting those found wanting. The BDA has identified a significant surge in the demand for advice on regulatory issues. It says:

"It is clear from our analysis that the challenges facing dentists are increasing and changing".

Paramount to its concerns is the growing burden that changes to professional regulation are placing on its practices and the impact it is having on the delivery of patient care. The BDA continues:

"Recent years have seen a significant and disproportionate elaboration of the regulation of dentistry, with the publication of new decontamination guidance and the advent of the Care Quality Commission. We hope that the (recent) announcement of the halting of the proposed vetting and barring regulations signal a fresh approach to regulation that puts patient care before bureaucracy".

Dental Protection, the dental branch of the Medical Protection Society, which I used to have the honour of chairing, reports an unprecedented demand for its advisory services. It says:

"The controls are out of control".

There is a widespread feeling in the profession, and a growing sense of anger and frustration, that there are too many hoops for practitioners to jump through, often resulting in a duplication of effort and with no real justification in most cases. The evidence base for many of these new requirements being imposed on dental practices is sketchy or non-existent. We desperately need a more balanced, logical and measured approach whereby any additional layers of governance are scientifically based and targeted where they are justified and most needed, rather than being applied across the board. The current environment is wasting the time, energy and money of many practitioners who are already doing an excellent job for their patients.

At a time when the new Government are proposing that high-performing schools should be inspected less often and freed from unjustified bureaucracy, the current excesses in the regulation of dental health professionals are impacting upon morale, deflecting effort and resources and ultimately not serving the best interests of patients. Now that many NHS practices are effectively operating on fixed incomes, any unnecessary expenditure in one area needs to be funded by cutting back on more constructive expenditure elsewhere.

I have received many letters from dental colleagues. I wish to quote from one that I received from Caroline Thornton, who practises in Gloucester. She comes from a family of dentists. Her grandfather was a dentist, as were her father, her brother and her husband, and she wants her 16 year-old daughter to become a dentist. She writes:

"We are trying very hard to conform to the avalanche of regulations piling up every day. However, in a recession, this is proving to be very expensive! We have spent thousands on a new sterilization room, paid for the nurses to be trained, registered, and their CPD up to date, CRB Checked, even though 2 are pregnant. We are having one of the surgeries revamped in August to make sure it is up to date with the HTN 1-5 regulations at a cost of £20,000, and even completed a clinical waste audit, amongst many other trivia, all at our own expense. At this rate we will have a lovely practice but be bankrupt!"

I could quote many other letters.

One detail that seems to be overlooked in this eagerness to be seen to be monitoring, documenting, auditing and acting, is that when assessing the risk presented by an underperforming dentist, it pales into insignificance when compared to an underperforming medical practitioner or surgeon. Before all this monitoring, documenting, auditing and acting became an art form, how much actual damage was being done to how many dental patients? How often and how serious were the consequences? Medics can kill people. Even at the very worst, dentists are unlikely to do so. I am tempted to wonder whether we are creating an entirely new industry and spending an awful lot of money "fixing" an illusory problem, or heading off the hypothetical threat of a "virtual" problem that may not even exist in reality.

Photo of Lord Rea Lord Rea Labour 3:03 pm, 24th June 2010

My Lords, I thank the noble Lord, Lord Mawson, very much for raising this important topic, and particularly for his inspiring description of his Bromley by Bow project. It reminds me of the Peckham health centre from pre-war days, which was a concept ahead of its time. It is now, sadly, closed. There is much we can learn from the noble Lord's project and his words this afternoon.

The noble Lord has worded his Motion constructively, concentrating on recent changes and the lessons to be learnt; basically, what has worked; what has not worked; and what might work better. If we were to start with a blank sheet, we would need first to look at the kind of health and social problems which the population presents-of course, the two are inseparable-both nationally and locally and then try to fit services best to tackle these problems. However, we have to build on what we have. As the noble Lord has described, this is far from ideal, but I am an optimist and I think that it is getting better. It is already a lot better than in many other countries.

Of course, we have an age pyramid typical of a western developed economy, getting top heavy with older people such as myself-there are more and more of them-and they are living longer and, sadly, becoming increasingly disabled, needing more care. Other than this demographic problem, the other main public health problem, which we share with the rest of the world, is the difference in health status between the best off and the worst: health inequality, in other words. This gradient applies throughout the social spectrum from top to bottom. We need to improve the health not only of the poorest but also of the middle of the range who have worse health than those on the next rung of the ladder and so on, as Professor Michael Marmot has recently re-emphasised. To restrict services such as Sure Start to the really poor and deprived does not tackle the relative health problems that exist, for example, between skilled and non-skilled manual and non-manual workers. There is work to be done right across the board.

Ideally there should be a gradation of health and social service funding taking into account the age and social structure of each community. To be fair, there has for many years been a serious attempt to do this, but the inverse care law still persists and it needs an even greater share of resources than we have so far allocated to it to reverse it. This might be politically difficult since if this was done on a tight budget, as now, and was in some years past, relatively well-off communities might have to accept a reduced budget. These communities know how to fight their corner, so it is a difficult situation. The health problems of ageing and inequality are deep-seated and have their root causes in the nutritional, physical and social environment of early childhood, which is largely outside the scope of the community health and social services. Even so, it is these services that have to cope with the lasting legacy: the social problems of young adults, including drink, drugs and crime and the chronic ill health of older adults.

Though those with chronic degenerative illness often need periodic admission to hospital, most of their care is appropriately and better done in the community. In a minority of cases "hospital at home", including procedures such as intravenous drips, is sometimes possible, avoiding admission or enabling early discharge rather than treatment as an as an inpatient. However, the Royal College of Nursing is concerned that the development of specialist home nursing teams such as advanced nurse practitioners, community matrons, specialist nurses, and consultant nurses concerned with managing serious illness at home is having a knock-on effect in reducing the recruitment of community nurses and health visitors, who are still vital in overall community care, particularly for the disabled elderly at home, and in providing mother and child care and preventive services. The transfer of much hospital care to primary and social care at home has long been part of government policy but is not always cheaper. Patients may be discharged too early and need re-admission-a process perhaps encouraged by the payment by results scheme, which can result in a hospital being paid twice, once for each admission.

For many years, GPs have increasingly come to accept that they need to work in teams-not all, I agree, but the trend is there-including other health and social workers to give a really effective service. There are still a few Dr Finlays out there who prefer to work on their own. They are very different from my noble and professional friend on the Cross Benches. The primary care team is now the norm and is encouraged by the National Health Service. As the noble Lord said, my noble friend Lord Darzi proposed a network of polyclinics in which there were more services and links with hospitals than in most group practices, but this proved to be a bridge too far for many GPs and their professional organisations. However, the concept has become more acceptable, provided that the centres are GP-led and tailored to local needs and development. Many GPs are concerned, however, that the polyclinic concept will lead to primary care groups being taken over by private profit-making healthcare companies. This has occurred already in some PCT areas. The one that I know is in Camden PCT, where the contract for practice was awarded to United Health in preference to a local GP group which was offering a better and fuller service, but at a slightly higher price. The results have not, as far as I am aware, been fully evaluated, but the local feedback is unfavourable.

The new contract for general practitioners brought about major changes, as well as a rather generous package for most GPs. The BMA had a sharp negotiating team and the Government needed the GPs to be on board. The biggest change was to remove the obligation to provide 24/7 out-of-hours clinical cover for registered patients. PCTs had to take on this responsibility. They have not found it easy and have often farmed the work out to private companies. Patients are not always happy to be seen by a strange, often foreign, doctor who does not know the area; and of course there has been the occasional tragedy, as we all know. This is a far cry from the days when I was a general practitioner, when we were responsible for after-hours care. Our group made it tolerable by collaborating in a consortium or rota, with other local GPs. In fact, the BMA negotiating team was prepared to continue with the responsibility, if the money had been right. In the end, however, the cost to the PCTs of providing the service was much higher than estimated; in fact, according to my information, it was greater than the amount that the BMA had originally asked for.

The other important part of the new contract was the QOF-the rather grandly named "quality and outcomes framework"-whereby GPs receive a payment for each procedure in a list of measures which assist in monitoring, and thus improving, the health of their patients. They include weighing, taking blood pressure, keeping disease registers and so on. I and some of our colleagues were sad that GPs had to be paid for measures which many of us regarded as part and parcel of good practice, and should have been part of any contract. However, it is clear that this carrot has increased the capacity of general practice to anticipate serious illness. The standard of practice has improved and some lives may well have been saved through, for instance, control of blood pressure and weight reduction. However, I am sceptical about the accuracy of some of the numerical extrapolations that have been made about lives saved. It would be good to know whether, without the financial incentive, this exercise will result in permanently better practice by GPs.

An alternative or addition to the polyclinic model has been suggested by the Royal College of General Practitioners. It proposes primary care federations, which are associations of primary and community care teams, as a legally binding enterprise. I am sure that that concept is not unfamiliar to the noble Lord, Lord Mawson. The college cites three examples: the Croydon Federation, consisting of 16 practices; Lincolnshire General Practices, which has14 practices; and Epsom Downs Integrated Care Services, where 20 practices are collaborating. These hold considerable promise, but I should like to see more involvement of social services and mental health teams, as well as appropriate parts of the voluntary sector. This is very much in line with the proposals of the noble Lord, Lord Mawson. As it is, these projects provide better-integrated primary and community care as well as more emphasis and better facilities for preventive medicine and health education. They could also help to form, through their PCT, a nucleus for practice-based commissioning, which so far has had little impact on services provided by hospital trusts.

Local collaborations such as this, which very much fit the ideas of the noble Lord, Lord Mawson, including voices from all the caring professions, are more likely than top-down decisions to provide or commission good services for their communities.

Photo of Lord Alderdice Lord Alderdice Liberal Democrat 3:15 pm, 24th June 2010

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Photo of Baroness Finlay of Llandaff Baroness Finlay of Llandaff Crossbench 3:28 pm, 24th June 2010

My Lords, I must declare an interest as a true Dr Finlay. I am a practising clinician; I am president of the Chartered Society of Physiotherapy; I work in palliative medicine; and I have links with many hospices around the UK. I hope that I have made all the declarations before I start.

We are facing change and I am sure that the Minister is inundated with advice and pressures but in the time preceding change, I hope that he will be cautious so that we do not have change while ignoring the potential unintended consequences of such change. One of the difficulties is that often we do not know what we do not know, and in the rush to bring about change we may not do the background research or explore the issues. I want to address the specialist services providing care for patients, the role of the third sector, particularly for terminal and palliative care, and the needs of patients out of hours.

In 2006, in England and Wales there were 503,000 deaths. That figure is anticipated to rise to 586,000 in 2030, which is a massive increase. Only about 20 per cent of patients die at home, so we have to think how the needs of all these patients will be accommodated. With that there has been pressure to move patients out into the community. The need for integrated care pathways for complex conditions increases as high levels of expertise are required to meet patient needs and there are more patients with complex conditions. I am concerned that in trying to save money substitution has been looked at but it is not without its dangers.

Despite a priority of providing care closer to home, the Audit Commission report, More for Less, found little evidence to show that PCTs have been successful in removing care from hospitals. There is little evidence that patients with rare, complex conditions are not prepared to travel to get expert care, because they know that they need accurate diagnosis and a really good management plan. The challenge is: how do we get patients seen by the right person at the right time in the right setting, as well as trying to move care out into the community? That is a stark cultural challenge that needs multiprofessional teams working in managed clinical networks to encourage collaboration and co-operation between primary, community and secondary care. That must also cover other aspects of home care provision, including social care.

The new commissioning arrangements must cross traditional NHS boundaries. The publication by the Royal Colleges of Physicians and General Practitioners, Teams without Walls, identified the need for integrated systems, clinical leadership in commissioning and aligned incentives, underpinned by patient involvement in commissioning systems, especially for those with long-term conditions.

The current problem is that payment-by-results tariffs in their present form incentivise against integrated care. The current tariff-based system encourages hospitals to treat more patients while, simultaneously, GPs are under pressure to refer fewer patients. That creates a tension that can work against the development of integration and against quality in patient care. It works against earlier diagnosis, particularly in recognising rarer and complex conditions. One way to rebalance the disincentive is to introduce payment by pathways or payment by conditions, to ensure that high quality generalist and specialist care have a sustainable future, for the benefit of patients.

Patients must enjoy equitable access to specialists when required. I have just chaired a joint report on allergies for the Royal Colleges of Physicians and Pathologists, and we have found a stark inequity in provision around the country. Specialist resources must be at the heart of any clinical network or community-based service. It is essential that we have services available 24/7. The current five-day provision does not meet patient needs. That service does not respond to the true, seven-day need of those who are really ill, including at night. In Wales, we have moved from five-day to seven-day working by clinical nurse specialists in palliative care, and we have shown in a short space of time a dramatic change, because problems that occur on Saturday will be dealt with on the Saturday or Sunday. By the Monday, it would have been too late to address them.

There are some specialist service needs where integration is essential. There needs to be a one-to-one relationship between the GP, the patient and the specialist in secondary care to ensure patient safety and that people understand the complexity of the patient's background. Repeated handovers do not work well. We know that information is being lost in a kind of conveyor-belt hand-over between clinicians. We need to restore patient safety and quality of care and ensure that the lead clinician has a comprehensive understanding of the patient to reduce complications and near misses, particularly in surgery.

Some things should be done only in places well equipped to do them. An increasing amount of so-called minor surgery has been done in general practice, but there have been some awful situations where melanomas have been removed, the margins have not been adequately marked, the resection was inadequate and the subsequent surgery was much more extensive and expensive than if it had been done in a specialist dermatology surgery centre at the outset. The Anaphylaxis Campaign has sent me horror stories of GPs giving advice to parents about children suspected of having a peanut allergy that was completely inappropriate and would have jeopardised the child's life, not just their health. It was just as well that the parents phoned the campaign with their anxiety.

There are real problems out there, and there are risks as well as opportunities in moving towards a largely GP-commissioned framework. Academic GP is essential to driving up the standard of evaluation. We need to evaluate patient outcomes in any change. This is not about having a fashion for one model or another; an evidence base must underpin commissioning. As PCTs are divested of their commissioning responsibilities, GP consortia are expected to take up the mantle, but their skills and background knowledge, and even their willingness to do this, are really deficient in some places.

There needs to be a national view on minimum access rates and the provision of highly expert services to avoid a postcode lottery, particularly where there is a low critical mass in a smaller population, otherwise you get a bidding war between GPs and consultants that works against quality. If you do not have adequate dual provision, community-based services will have fewer places to turn to for training specialists for the future, for continuing professional development and for research. Driving that forwards will drive up standards of care in the future, particularly for those with more complex conditions.

I ask the Minister to consider some specific things: that promoting the idea that engaging doctors in the spirit of collaboration is required for successful commissioning; that commercial loss leaders might appear at first sight to be useful but may lose expertise and undermine quality in the long term; that the repudiation of unhealthy forms of competition is essential, as is encouraging jointly commissioned models for integrated health services; that choice for patients means the ability to access specialist scientifically based clinical excellence to diagnose and plan their management, which can then go back for ongoing care in primary care if there are good pathways; and, lastly, that the incentives and disincentives of payments by result need to be rebalanced to bring integrated generalists and specialist care closer to the patient's home.

I am grateful to the noble Lord, Lord Alderdice, for flagging up the importance of the whole person and the whole family, because the third sector provides that par excellence in hospice care. There is a need to specify minimum levels of service, such as in hospice care, across the UK, and to have centrally agreed three-year contract with an agreement on how the service is delivered locally. At the moment, Marie Curie has to negotiate 200 separate contracts across the UK. That is a waste of time and a duplication of effort when models such as the fire service or the police demonstrate that you could have a national framework with local agreements on implementation.

Hospice grant money has to be negotiated at a local level by small hospices that often do not have much expertise in negotiating with all the different people from whom their patients come. Competitive tendering is punitive to the third sector, because it does not have the resources to tender or the expertise of larger bodies. Punitive contracts in the third sector can really work against them. If they miss a level in their service they may incur a penalty, yet they provide a key service to the NHS.

Commissioning must become outcome-related, as much in hospice care as anywhere else. Currently, it seems to be process-related. It has to be integrated across the whole pathway, and this need to commission across the whole pathway means that the professional competency framework needs to be driven up to promote higher levels of competency. There is a real concern and a danger that private companies will come in and commission against a whole pathway, and one questions why they are needed as an intermediary. The danger is that increased income will go in profits to shareholders and not be reinvested in the not-for-profit third sector that the hospices epitomise.

In summary, there needs to be 24/7 provision, which should be addressed urgently. There is a large shortfall in district nursing. Only 53 per cent of PCTs have 24-hour district nursing, which is grossly inadequate if you are trying to care for critically ill patients at home. There has to be a closer link between health and social care. Care assistants can often be the key people to keeping patients at home.

On incentives, we should remember that healthcare professionals are proud. They want to deliver a good service. If you embed direct patient feedback into the system, as we have in Wales for palliative care using iWantGreatCare, it can become a powerful driver to quality improvement. One team does not want to perform less well than another, but patients need to provide feedback in an anonymised way so that they are not fearful that their comments might antagonise the clinicians looking after them.

There have been unintended outcomes from the current arrangements where financial incentives or punishments drive provision rather than need. Patients feel particularly lost out of hours and it is really important in commissioning healthcare that we get it right. There is a steady stream of horror stories coming through. It is not simple; it is not like shopping for shoes; and I hope that the Minister will think carefully about the unintended consequences of change.

Photo of Lord Crisp Lord Crisp Crossbench 3:40 pm, 24th June 2010

My Lords, I, too, congratulate my noble friend Lord Mawson on inviting us to reflect on primary care over the past 10 years and more. I know he is hopeful that his timing is such that the Government's policy is not yet so rigid that they cannot listen to new ideas and the practical lessons that he and others want to mention. I have to declare an interest. Most people know that I was chief executive of the NHS in England for six years. There is a lot that I could say, but I will concentrate on the same areas as my noble friend; namely, the integration of care, particularly thinking about social care, education and other boundaries around the whole person.

The other day, an American friend said to me, "We love you in England because you keep changing the way you develop primary care. You are a wonderful laboratory. You have tried out lots of different ways of doing it". I guess that that is true. But I guess that there is a reason for that, which is not just a wish to meddle. It is that, as other noble Lords have mentioned, a lot has changed in the 70 years since the 1940s, when we set up the primary care system we have now. The three big changes have been referred to by others. The diseases are different. Seeing patients is much more about dealing with non-communicable diseases. They are about elderly people with complex or multiple problems. The patients have changed. They are much more demanding, but their behaviour is much more important in so many ways in terms of the management of care for diabetes or whatever. In addition, technology has changed. All those changes mean that our old model has led to shift. As we have noted, there have been many ways in which people have tried to make that shift. It is really important that we learn the lessons from those attempts to change and to make improvements.

Before this debate, the Royal College of Physicians wrote to me and, I suspect, to others saying that it was really important that we did not lose sight of the fact that primary care, secondary care and tertiary care need to join up. We need to have that all within the frame. It is interesting to reflect that the separation between primary care and secondary care is largely in legislation that is about 70 years old. It is not writ that a GP shall be this and a consultant shall be that. It was an organisational change. The way in which parts of the medical profession relate can change and some organisations, as I think that the noble Lord, Lord Alderdice, mentioned, employ or involve both. There is nothing rigid about this.

However, I want to talk about integration around the patient. Let me go back to the simple point that most patients today in richer countries are people whose needs often may be clinical, but alongside that there is a need for independence. I think that I have mentioned in this House before that my elderly father fell and broke an arm. Clinically, it was very easy to deal with, but the real issue was whether he could remain independent and live at home by himself. That is the sort of situation we are talking about in terms of many of the patients that the NHS deals with. Indeed, many patients with the highest expenditure in the NHS are those with complex problems that span clinical, social and other needs. So it is welcome to see primary care playing a major role in prevention and in helping patients find their way around the system.

Primary care is not just about GPs, and it is important to keep the two separate. There are different roles for many different people. One of the saddest pieces of research I have seen was published some years ago. It concerned young people suffering from depression and how they were treated in primary care and whether they were able to be taken seriously. There were too many accounts of people going to GP surgeries and being told to come back in three months if it was getting worse. In effect, they were being turned away. We need different routes in primary care for those who sometimes find it difficult to express their needs.

That takes me on to the issues raised by the noble Lord, Lord Mawson, about health and social care, and other areas such as health in education. He asked how far we should go to ensure that we have health provision in schools, whether in the form of health services or whether they are designed into the architecture of schools. He also asked if we should have local partnerships that are able to focus on what is needed. The noble Lord concentrated on social entrepreneurs, but I know that he, like me, is interested in how local partnerships made up of the right groups of people can have an enormous impact on a local environment in terms of health benefits and the related issues that go alongside them. By local partnerships, I am not just talking about individual organisations that bring health and social care together, but about partnerships that bring together everyone who has something to offer in this area. These can be quite difficult to conceptualise and describe in order to determine the policy that will promote them, so I would encourage the Government to look at some of the ones that work.

As I said, the noble Lord, Lord Mawson, referred to a number of social entrepreneurs and one or two exceptional GPs who have set up extraordinary practices that go way beyond what we would traditionally think of as healthcare. But I think that some of our PCTs have done exceptional things in trying to address inequalities, particularly in areas like mental health where we know that among the best things you can do for patients is help them to get jobs and housing. Among the range of entrepreneurial PCTs let me mention one particular group I know of and declare an interest in. Something like 20 UK PCTs are part of a group called Triple Aim. They are working alongside similar organisations in Scandinavia and the US, facilitated by an American organisation called the Institute for Healthcare Improvement. Here I declare my interest because I am working with the organisation in Africa rather than in this country. It would be interesting for the Minister and the Department of Health to look at what these PCTs are trying to do by taking on a triple aim-to improve the health of the population, improve the care given to individuals, and reduce costs. They are doing so by trying to integrate with local partners. There are some good examples that we can build on and, taking a completely different example, a number of schools in this country have health facilities within them. So I urge the Government to look not just at the social entrepreneurs referred to by the noble Lord, Lord Mawson, but at the organisational people working within the system who are trying to make these things work; they go very much together.

Finally, I come back to the issue of primary care trusts and GPs. I have seen some statements from the Government about giving GPs and doctors more control. I understand and appreciate that. One of the great merits of the NHS that shows up in any comparison with other systems around the world is its primary care. This is one of our great strengths, among others, and we must preserve it. But however wonderful some GPs are, not all of them are. They are not all capable of taking on all the roles that we might think we would like them to. I pay tribute to the last Government because they were concerned about variations in performance between hospitals and did a great deal to bring the performance of the poorest up to the best. Among GPs, not surprisingly because there are so many of them, that range of variation is much wider. Sometimes we talk about GPs as if they are all the same, but to me that feels like something of a mistake.

Another issue in developing policy around GPs in the context of primary care is the potential for conflicts of interest, and again I suspect that the Department of Health has good examples of where, by putting more money into primary care decision-making hands, potentially and only in some areas you end up with conflicts of interest about how the money is spent. But-and it is a very big but-we have also seen great benefits from having primary care and GPs taking a lead. In particular, it is interesting that in a number of practices where the GPs have budgets and have taken a bigger lead around commissioning, they have changed the services they provide and the job roles of people. Increasingly you see people other than individual GPs when you attend a GP practice. That is all for the good, in both quality and cost terms.

I am reminded that 15 years ago we were trying to get more GPs into east London and tried to do so by recruiting salaried GPs-in other words, by moving away from the current model of GPs being self-employed. We were told we could never do that: it was not what GPs were about and it was essential that GPs were independent. I see the noble Lord, Lord Rea, nodding his head. However, we succeeded to some extent in making that happen but now it has all changed. Today, in practices where GPs are responsible for budgets and direct care, there are many salaried GPs and many people doing different kinds of jobs. That would not have been possible had you tried to make those changes from above. Indeed, GPs in London complain that they cannot get jobs as partners any more; there are now salaried jobs but the partnerships are being kept in fewer and fewer hands.

While that may be a downside, the important point is that doctors, as part of the entrepreneurial culture to which the noble Lord, Lord Mawson, referred, have the ability to make changes that mere managers, politicians and others from outside would find it difficult to make. It is important to build on that.

I hope that, like the noble Lord, Lord Mawson, the Government will look back on the years of change and development and learn the practical lessons. I should like to ask two specific questions. Will the Government look at innovative PCTs as well as innovative entrepreneurs, and perhaps consider Triple Aim as an example? How will the Minister clarify the relationship between PCTs and GPs in the future? I suspect this is one of the areas in which there is some confusion in the service at the moment over how primary care will be led, planning will be done and life will move on over the next few years.

Photo of Baroness Emerton Baroness Emerton Crossbench 3:53 pm, 24th June 2010

My Lords, I, too, warmly congratulate my noble friend Lord Mawson on, first, introducing the debate but, more importantly, on demonstrating through his entrepreneurial approach what has been achieved in managing change of this magnitude in what at first sight must have seemed an impossible task.

We have had put before us lessons taught in managing change through people to provide a community service in every sense of the word. Like many other noble Lords, I found my visit to Bromley by Bow Centre a manifestation of real entrepreneurial skill- second to none in demonstrating holistic care in the most imaginative ways-which became not only productive in outcome but engaged the patients and community members in a non-conventional way. The emergence of a true community was evident. I found my noble friend's book very gripping, for no punches were spared in the description of both the barriers and the successes.

I declare an interest as a retired nurse. Over the past 10 years, much progress has been made in community services to encompass a wide range of services, including public health and prevention services, but despite many primary care and community initiatives we still have a long way to go on early identification of disease, risk factors, reduction of health inequalities and the promotion of child health. In the development of urgent care, acute care at home and end of life care services, community services work in close partnership with the GPs, hospital services and social services to support the independent living of older people and the safeguarding of vulnerable adults. They also work with children's trust partnerships. Currently, 200,000 staff are employed to meet these services, requiring £10 billion from the NHS budget. There is considerable evidence of widespread variation in productivity, which, if addressed, could generate a substantial direct improvement in service quality and sustainable efficiency, thereby reducing costs.

During the past 10 years, attempts had been made by the previous Administration to improve services through the recommendations in the NHS Plan, published in 2001, the general medical contracts in 2004, and the White Papers, Our Health, Our Care, Our Say in 2006 and Transforming Community Services, published last year. The Nursing and Midwifery Council, its regulator and its predecessor, the UKCC-of which I declare an interest as a former chair-have long supported the provision of healthcare in the community. During the previous decade, they introduced specialist community practice awards and created a specialist community health nursing part of the register. These measures acknowledged the shift in expertise needed to ensure safe community practice. While not yet enforced, the emerging standards for pre-nurse education will require pre-registration students to spend 50 per cent of training in practice-based settings, which will increasingly be within the community as services are reconfigured. This represents a sea change in nurse education and will herald a major improvement in healthcare delivery at the point of registration. The planned 4,200 increase in the number of health visitors is admirable. They play an important cross-professional, co-ordinating role, leading skill mix teams in delivery, postnatal, early-years and family healthcare.

However, it is important that health visitors retain a grounding in basic nursing and/or midwifery skills. Knowledge of diabetes, associated obesity, childhood ailments, immunisation, prescribing and disease management are all essential to ensuring safe delivery of patient care pathways. The Nursing and Midwifery Council is looking for the best way to take forward the preparation of health visitors. Will the Government support this initiative?

The introduction of matrons, advanced practitioners, specialist nurses and consultant nurses in the community has resulted in many patients with complex, long-term conditions being expertly cared for without the need to frequent their local hospital. Community matrons in particular are striving to help people with long-term conditions become more self-reliant and better informed about their health and how to improve it. This reflects a shift in emphasis towards nurses helping to empower patients to look after themselves and manage their conditions better.

The programme to support practitioners to transform services and deliver high- quality care and productivity set out evidence for best-practice care within community services through a series of six transformational reference guides entitled, Health, Well-Being and Reducing Inequalities; Services for Children, Young People and Families; Acute Care Nearer to Home; People with Long-Term Conditions; Rehabilitation Services and End of Life Care. All of them provide a guide to high-impact changes and are intended to enable practitioners to give high-quality care.

The continuing work is looking particularly at the needs of frail, elderly patients with complex health conditions. They are the main service users of community healthcare and now occupy the majority of acute hospital beds. Increasing evidence points towards a wide variation in the care offered to the elderly. Studies indicate that up to 30 per cent of people in hospital at any one time, many of them frail and elderly, could be safely cared for in the community with the right access to community services and appropriate support. There are efforts to mobilise staff using evidence to create a "social movement" among front-line staff and empowering clinicians to lead change and innovation. This leads to the use of care pathways to increase care co-ordination and best practice for patients. Combining primary, community, hospital and social care to increase efficiency and provide high-quality care, it is best described as "care without walls".

At present, a high proportion of residential nursing homes employ healthcare support workers and social care workers. Evidence from a study conducted by Ian Kessler at Oxford University shows that many undertake aspects of care traditionally done by nurses but that they are not trained to do it safely. If there is to be an increase in community care, increasing the level of social carers and healthcare support workers, there must be an increase in safeguards on the roles undertaken by those staff. With no form of regulation in place, it is difficult to track and prevent those unable to provide safe levels of care. The move to community-based care poses a significant risk to patient safety.

Against a background of the demographic growth of the elderly population-requiring an increase in both long-term and acute home care-of the care of vulnerable children in pre- and post-natal care and of changes in the pattern of commissioning services, it will be important to ensure that at every level a nursing voice will be able to ensure the safety of patients as well as the delivery of high-quality care in the most cost-effective way. It is imperative that the new systems of commissioning primary and community services enable the voice of an experienced nurse to ensure that the resources and training facilities in clinical placements are sufficient to meet the need.

The Royal College of Nursing continues to express its concern over the lack of investment made into the community nursing workforce. A particular concern is the problem of the ageing nursing workforce, as 27 per cent of nurses working in community services within the UK are aged over 50. Over the next 10 years around 180,000 nurses will be eligible for retirement, leaving a huge hole in the workforce which, at current levels of commissioning, will not be met by future recruits. There are concerns that the problem will be magnified through the current period of financial constraints by recruitment freezes and the deletion of posts as a result of efficiency savings. There has also been evidence of an active reduction in student places being commissioned, despite a record number of applications to enter the nursing profession. This, it says, is a great disappointment and a blow to all that has been done to improve the attractiveness of nursing as a career.

The leadership skills required are of paramount importance and it is through people rather than policies that change can be affected. The challenges of overcoming the barriers between various services are enormous but the opportunity to grow community services must not be lost. Just as my noble friend mentioned, it takes time to break through the barriers and that cannot be rushed. Certainly, in my experience of leading and managing a project relocating 1,500 and then a further 1,200 learning disability patients from two large hospitals, it took 10 years to ensure that every patient was individually assessed, relocated according to their needs and placed into the most appropriate accommodation. That involved seven London boroughs and two county councils-none of which was keen to take back its residents-while ensuring that staff were appropriately trained to care for residents in the community, which was completely different from being within the large hospital and a big culture change for them. There were relatives reluctant about their relatives to transferring from the safe environment provided by the large hospital to an open community and there was the receiving communities' reluctance to receive learning disability clients.

While there was an overall strategy accompanied by a critical path analysis setting target dates, that project really required hours of careful negotiation through the barriers to result in a changed culture-one providing a more meaningful style of life for clients in a safe environment, while delivering high-quality care and management. Managing such an innovative project, as with those that we have heard described this afternoon, was certainly a huge learning curve for me-and, I am sure, for others. I believe that there is an urgent need for nurses and all healthcare professionals to gain the necessary leadership skills to be equipped to meet the challenges and opportunities of the future's reconfigured community services.

Photo of Baroness Thornton Baroness Thornton Labour 4:04 pm, 24th June 2010

My Lords, this is an interesting subject for debate, as the debate has proved. Learning the lessons of the past 10 years at the moment when great change is about to be unleashed on the whole way in which healthcare is delivered in the UK seems appropriate, and I congratulate the noble Lord, Lord Mawson, on his usual entrepreneurship in the timing of this debate and the passion that he brings to the issues of innovation in providing public services-in this case, healthcare-as well as his hopes for less bureaucracy, less political change but not, I hope, less accountability. The noble Lord has been making this kind of wonderful speech for as long as I have known him. Rightly, he blames bureaucracy and politicians in his passion to roll out the models that he knows so well and that work so well. As he knows, I have a great commitment to social enterprise and entrepreneurship, but I think that he needs to give some credit where it is due about the progress of the past 10 years.

I remind the House that some progress has been made. I should like to look at two issues-the LIFT programme and the development of social enterprise in the past 10 years. The LIFT programme, delivered through community health partnership, is there to create, invest in and deliver innovative ways in which to improve health and local authority services. I know that the noble Lord, Lord Mawson, is familiar with the LIFT programme and has tales to tell about the difficulties of this bit of the bureaucracy. But it is there to deliver and provide clean, modern, purpose-built premises for health and local authority services in England. The reason why the programme is so important is because 90 per cent of patient contact with the NHS occurs in general practice. The research shows that primary care in the inner cities, where healthcare need is the greatest, may have suffered from a disproportionately high number of substandard premises in primary healthcare. That is why we instituted the LIFT programme. We knew that the condition and functionality of existing primary care estate was variable, with current facilities not meeting patients' expectations and quality and access often being below an acceptable standard-and, therefore, service development sometimes very severely hampered by the limitations of the premises.

As a Government, we made an investment in primary and social healthcare facilities. We made it a priority in inner-city areas. It was clear to us that new buildings were required to provide people with modern, integrated primary care services. When we came to power, there is no doubt that the creation of new facilities was fragmented and piecemeal. Developments tended to be small scale and focused on more affluent areas; they tended not to integrate social care at all. The landscape has been transformed in the past 10 years. If I add to this the review done by my noble friend Lord Darzi, it is clear that we have made some progress.

I shall mention some of these outcomes and particularly draw them to the attention of the noble Lord, Lord Mawson. He said that he was tired of words and no delivery. Well, there has been a huge amount of delivery-in fact, £2.2 billion worth of delivery of new schemes. I take for example the centre at Church Road, Manor Park in Newham, which the noble Lord may be familiar with. It brought together three GP practices and contains district nursing as well as health visitors, dentistry, pharmacy and many diagnostic services. Then there is the Thurnscoe primary care centre in Barnsley, which has, among other things, eight GPs and traditional primary care services; it is able to do blood tests, ultrasound scans and minor procedures, which means shorter hospital waiting times. It also includes an ICT training suite, a GP training room, an audiology clinic, a podiatry clinic, district nursing and physiotherapy.

The one that I like best is the Kenton Resource Centre in Newcastle, which was built on the site of an old clinic on Hillsview Avenue. It has a new health facility, including the relocated GP practice, but it also includes community health professionals, Newcastle City Council and voluntary services, a local customer centre, which provides housing and benefit advice, a Newcastle City Council library, which serves three neighbouring districts, and a Northumbria Police office for local beat officers.

I could go on. In fact, the most recent centre was opened last week in Dudley-the new multimillion-pound state-of-the-art Brierley Hill centre. Therefore, I think that we can say that we have been delivering local community centres in the last 10 years, but I ask the Minister what the fate of the programme will be. How will it fare in the reconfiguration of the NHS that we are told is on its way?

Let us turn to social enterprise. I declare an interest as a serial offender in social enterprise. I have spoken many times in your Lordships' House about the development of social enterprise and I have sponsored things such as the community interest companies Bill. I think that it is worth saying for the record that social enterprise is a business whose objectives are primarily social and whose profits are reinvested back into its services for the community, with no financial commitments to shareholders or owners-it is free to use its surplus income to invest in its operations to make them as efficient and effective as possible. Well known social enterprises include Turning Point, the Eden Project and the Big Issue.

The Department of Health has been promoting social enterprises through the initiatives that the Labour Government took, as we saw the advantages of them for patients and service users. We instituted the right to request as part of our broader vision for the NHS. I know that the first phase of the right to request has been enacted and I think that the second phase is about to be enacted, but I should like confirmation of that from the Minister. I should like to know what will happen to the social enterprise investment fund and to the right to request.

I should specifically like to know from the Minister what will happen to contracting, although he may not be able to give me an answer right now. The Labour Government made a commitment through the department that, when a social enterprise had been established in the health service, had gone through the right to request and was contracting for services, that enterprise would have a three-year or possibly a five-year contract, which would be guaranteed once it had gone through the whole process. Will that continue under the new regime? If the Government are serious about developing social enterprises to deliver primary healthcare and other services within the health service, a contract of three to five years will be vital for those businesses.

The noble Lord, Lord Mawson, talked about the Bromley by Bow Centre, which is a tremendous achievement. I should like to mention the Big Life centres. The Big Life is based in Manchester. It grew out of the Big Issue and works with people completely cut off from health, housing and employment services. There are now eight or 10 centres providing holistic services to the communities in which they are based. The Kath Locke Centre combines the best in conventional NHS healthcare with complementary therapies. It is well built and a good place to relax, and is extremely well used by its local community.

The Big Life Group issued a manifesto for the last general election, which I commend to the Minister. It states:

"We believe, developing a market in the NHS has really only meant opening up to large private sector companies and has largely missed the opportunity to bring in innovation through the social enterprise sector".

I do not agree completely with that: it may be as unfair as some of the comments made by the noble Lord, Lord Mawson. However, the Big Life Group may have a point. We as a Government did not succeed as much as I wish we had. The challenge is now there for the coalition Government. If they are serious about having an innovative marketplace, they must address the issues raised by organisations like the Bromley by Bow Centre and the Big Life Group.

I agree with the noble Lord, Lord Mawson, that the department must encourage more entrepreneurship. Like him, I have been frustrated by slow progress across the piece. As the founding chair of the Social Enterprise Coalition some 10 years ago, I think we should blow our own trumpet. Where there was one Bromley by Bow, there are now many. Social enterprise was mentioned in every party manifesto, and is now part of the coalition Government's programme. We have made great progress. However, there are still huge challenges.

I have some questions for the Minister. It seems that in two years' time, £60 billion of NHS funding might be funded through local commissioning, as the noble Lord, Lord Crisp, mentioned. What will happen to these schemes and programmes if this reconfiguration of the NHS is going to be so profound? How will the Bromley by Bows and the Big Life centres be developed under those circumstances? How will this entrepreneurship be taken into account in the new commissioning scheme? The noble Baroness, Lady Finlay, made a valid and wise point: the rush to change might jeopardise what has already been achieved through partnership and innovation. I agree with the noble Lord, Lord Crisp, that we do not want to lose some wonderful examples of PCT innovation in the forthcoming reorganisation. How will the coalition Government build on the platform that we created-or do they intend to dismantle the platform, with all the risks that go with that?

Photo of Earl Howe Earl Howe The Parliamentary Under-Secretary of State for Health 4:17 pm, 24th June 2010

My Lords, I begin by expressing my gratitude to the noble Lord, Lord Mawson, for the opportunity to reflect on the changes to primary care over the past decade. Perhaps I should start by confirming the basic principle that the Government will uphold the guiding values of the NHS; that it should be available to all, free at the point of need and based on need and not ability to pay.

For more than 60 years, our system of primary care-the local family doctor-has been the bedrock of the health service. When we are ill, our GP is our first and often only port of call. They are the prescriber, the referrer and the gatekeeper to the vast and often complex labyrinth that is the NHS. Few things are as local as your GP practice. By definition, GPs are of the community and perfectly placed to reflect and respond to the needs of the community. The problem that they face now is that they serve two masters; the patients whom they see every day and the targets imposed from above. However, we believe that, freed from central control, incredible things are possible, as we can see from the rise of the social entrepreneur.

Earlier this month, my right honourable friend the Secretary of State visited the extraordinary Bromley by Bow Centre, of which the noble Lord is the founder and president. Based in one of the most deprived parts of the country, it demonstrates what can be achieved with vision, determination and commitment. It helps people to overcome poor health and unhealthy lifestyles, to learn new skills, to find work and to create an enterprising community. It has been an inspiration to many in Bow and it is an inspiration to this Government.

The noble Lord, Lord Mawson, is right. By responding to local people and by being led by them, the Bromley by Bow Centre and other social enterprises are transforming communities in a way that the state cannot. This is the big society in action. Far from supporting them, however, the state has too often acted as a barrier to social entrepreneurs, limiting what is possible. This needs to change.

A damaging recent development has been the introduction of "preferred provider"; in effect, preferring adequate care delivered directly by NHS organisations over excellent care provided by others. We will encourage "any willing provider" to compete to provide the best outcomes for patients. We will give public-sector workers the right to form employee-owned co-operatives so that they can then bid for and deliver services themselves. We will support the creation and expansion of mutual organisations, co-operatives, charities and social enterprises. These will have a place, above all, in the provision of community services, with the quality of those services driven by innovative approaches to delivery.

Rather than preventing social renewal, government should be a catalyst to encourage and galvanise it; "putting the wind in people's sails", as the noble Lord, Lord Mawson, put it. As he said, there are some excellent examples of where the state already does this without working in silence. In Southend-on-Sea, the St Luke's Healthy Living Centre, in partnership with a local primary school, local residents and a wide range of grassroots representatives, provides counselling services, an allotment and food co-operative, advice services and a business support unit. Another social enterprise is Open Door in Grimsby. Open Door works in partnership with local public services, voluntary organisations and Santander bank. Most of all, however, it works with those it supports-the homeless, drug-users, refugees-to give them the help they want rather than the help that others assume they need. Both have enjoyed the support of the Department of Health's £100 million Social Enterprise Investment Fund, one practical example of where the state can help. The noble Lord, Lord Crisp, mentioned the work being done by some PCTs under the triple aim barrier. Like him, I commend those initiatives.

The crucial thing is what is delivered-the clinical outcomes and the benefits to patients and residents-not who delivers it. As the noble Lord, Lord Mawson, said, it is about doing, not just talking. This is all part of a massive redistribution of power and control away from the centre to individuals and local communities.

While at the Bromley by Bow Centre, the Secretary of State described our approach to healthcare. These principles are not plucked from thin air but, rather, are garnered from the experience of those parts of the NHS that already deliver truly excellent care. First and foremost, because decisions that include the patient lead to better clinical outcomes, we will place the patient at the heart of everything the NHS does. As the Secretary of State put it, there will be,

"no decision about me, without me".

Secondly, because what matters most to people is that they receive the very best quality of care, not that their hospital can jump through bureaucratic hoops, the NHS will focus on constantly improving clinical outcomes. We will hold the NHS to account for what they achieve, not how they achieve it.

Thirdly, because there is a limit to the improvements that can be driven from the top down, and we have long ago reached that limit, we will empower professionals. Over the past decade, the NHS has been showered with money, which is marvellous. However, it has also been drowned in red tape and bureaucracy. The Government intend to set the NHS free, not shackle it with centrally imposed process-based targets.

Fourthly, preventing disease will be as important as curing it. What has really improved the nation's health? Is it the National Health Service? Of course it is. Mass immunisation programmes and more recent things, such as the smoking ban, have also saved lives and helped well-being. Beyond a narrow focus on health, improvements in housing and sanitation have been just as important. Health cannot be placed in a silo. That is why public health will play a significantly greater role.

Fifthly, people do not differentiate between healthcare and social care-they just want help. Better social care can often prevent the need for expensive healthcare. For example, fitting a hand rail costing £70 can prevent a fall that would require a hip operation costing £7,000. Therefore, we must properly integrate health and social care, especially if we are to deal with the effects of an ageing population. These are the principles that will underpin our approach to healthcare, but to improve health outcomes we must bring these principles to life.

The Quality and Outcomes Framework initially helped to raise standards, especially in more deprived areas. However, it did so at significant cost and the improvements have now stalled. I was in considerable sympathy with much of what the noble Lord, Lord Rea, said about this. We will reform the QOF to reward GPs for improving health outcomes. We will also discuss with the profession how patients can help to shape the care they receive. We will also look again at the GP contract. Taxpayers must get value for money in return for the massive investment that they have made in primary care, and the contract must properly reflect and reward what we are asking GPs to do.

Whoever provides health services, high quality commissioning is essential and should be done as closely to the patient as possible. GPs and their primary care colleagues are in the best position to know what services their patients need and will have the power to commission them. In this way, they will also take ownership of the financial implications of their decisions, leading to better value for money. That is not something that they can do in the fullest sense at the moment. This requires leadership. As commissioners, GPs and their colleagues will become the leaders of a more autonomous NHS, supported nationally by a new NHS commissioning board.

Twenty-four-hour urgent care is currently unco-ordinated and of variable quality. We plan to overhaul that system. Nor should we overlook the role of the pharmacists. Every day millions of people visit their local pharmacy. With the right incentives and support, pharmacies can deliver both clinical and public health services. We will also build on the progress that has already been made in recent years.

The noble Lord, Lord Rea, in his excellent speech, pointed to the differential funding of primary care trusts and urged the Government to take account of differing health needs and deprivation. The noble Lord raises an important point. We are committed to ensuring a fair allocation of resources to the new GP commissioning consortium when it is formed. We also want allocations to be made based on the health needs of the registered population for these groups, so that those with the greatest need have their fair share of resources.

The noble Lord referred to the document produced by the Royal College of General Practitioners, which proposes GPs' practices working together in a federation to support each other in the provision of care to serve the local population. These are sensible proposals and we want to build on them, for GPs not only to provide a wider range of care and services to their patients, but to commission wider health and care services for the population. It is right that GPs' practices themselves decide on these federations. We are not prescribing those nationally from the centre.

This very much brings us to the concerns voiced by the noble Lord, Lord Crisp, and the noble Baroness, Lady Finlay, relating to the varying capabilities of GPs and how those who feel less confident and keen about commissioning can be supported. It is very much about GP collaboration. Everything that the noble Baroness said about this was absolutely right. The new GP commissioning system that we are proposing will be led by groups of doctors at a local level and overseen nationally by an independent NHS commissioning board. This is not about trying to turn GPs into managers; it is about placing the financial power to change health services in the hands of those NHS professionals whom the public most trust. Giving more responsibility and control over commissioning budgets should help GPs consider the financial consequences of their clinical decisions. This will lead to reducing waste and bureaucracy. Much will depend on the size of GP consortia, but I am confident that the necessary leadership will emerge from those consortia to facilitate the spread of best practice.

The noble Lord, Lord Crisp, sought clarification on the arrangements and the roles of GPs in commissioning services from primary care. We will be bringing forward proposals for change to the roles and responsibilities of GPs before the summer through a White Paper. Shortly after that we intend to publish a consultation document on GP commissioning arrangements. That consultation document will set out in a lot more detail the roles and responsibilities that we are proposing for organisations. We will welcome views and comments from all interested parties.

The noble Baroness, Lady Finlay, referred to the unintended consequences of change, the challenges posed by patients with complex conditions and the requirement to treat those patients in the right settings and along the right care pathway. She is spot on in all that she said. She referred specifically to payment by results acting as a barrier to integrated care. The work that we are doing to underpin our drive to an outcomes-based model of commissioning includes work to refine the tariff to embrace long-term conditions, co-morbidities and complex cases. This is a major undertaking but it is essential that we get there.

My noble friend Lord Alderdice remarked that there is a limit to managerialism. I am right with him on that. The Government are committed to a patient-led NHS, strengthening patient choice and patients' management of their own care. That will involve pro-active, preventive and personalised care planning with a focus on shared decision-making. That will apply especially to the care of people with long-term conditions, a theme pursued very powerfully by the noble Lord, Lord Crisp, and one which brings us back to the wise advice of the noble Baroness, Lady Finlay, on the management of change. We are developing a national support programme aimed at accelerating improved long-term care management. The aim is to realise the benefits of improved quality and productivity more rapidly through a large-scale change management programme that will disseminate good practice.

Front-line staff are, of course, crucial to the delivery of personalised care planning. More needs to be done to support the wider culture change that empowers people with long-term conditions to take more control so we plan to support the workforce with guidance and training resources. There is a clear message here: personalised care planning underpins good management of long-term conditions. The care planning process is about involving people with long-term conditions in discussions about their own goals and outcomes for the way they want to live their lives and then agreeing a plan with them on how their care will be managed. It is about addressing their full range of needs: personal, social, economic, educational, mental health and others. That is the way that we will empower people and get them to understand what choice really means.

The noble Baroness, Lady Emerton, in a speech to which I cannot possibly do sufficient justice in the time available, referred to the essential role of community nurses. We are determined to address health inequalities and improve public health. Nurses are key to this, as are health visitors working with families, communities and Sure Start and school nurses working with school populations. They will make skilled and significant contributions to this. We are committed to increasing the number of health visitors in the workforce to provide the best health, well-being and support services for all children and families and to improve services for those who need additional support. The noble Baroness was right in all that she said about the skill set of nurses. Health visitors in particular combine a nursing or midwifery and public health education which gives them the ability to put together a medical and psychosocial knowledge with an understanding of the health system. That is a unique strength.

The noble Baroness, Lady Emerton, referred to the challenges to the nursing workforce and its role in providing community services. She will know that four years ago the Modernising Nursing Careers initiative was launched jointly by the four UK chief nursing officers, with clear priorities. Those priorities were developed to ensure that nursing careers supported health reforms. The programme developed national tools and levers to enable local transformation of the nursing workforce. We will follow that theme.

The noble Baroness, Lady Finlay, referred to a 24/7 service. We are committed to providing universal access to high-quality urgent care, whereby people can have the care that they need whenever they need it. I anticipate that we will shortly make further announcements on that theme.

The noble Baroness, Lady Thornton, asked about the LIFT initiative. I agree with her that much good has emanated from it, and it has the potential to continue delivering. There are a possible 144 new schemes in the pipeline, worth £1.2 billion in total. There are also two new express LIFT companies in procurement that are due to become operational in this financial year. She also asked about social enterprise. I hope that I have said enough to convince her that we are serious about this. A number of initiatives, including using funds from dormant bank accounts to establish a big society bank, will be helpful. This is also about training. We need a new generation of community organisers to support the creation of neighbourhood groups across the UK, especially in the most deprived areas.

My noble friend Lord Colwyn moved us to the subject of dentistry and specifically the regulation of the dental profession. Dental practices will be required to register with the CQC from April next year-the date set by the Health and Social Care Act regulations. I recognise the fear of overregulation that dentists may have and I am well aware of the importance of good morale. My clear understanding from the CQC is that it will look at evidence that outcomes are being met, rather than adopting a tick-box approach to compliance. Where possible, the CQC will use existing information held, for example, by the Dental Reference Service, to minimise the demands on dentists. The CQC is agreeing a memorandum of understanding with the General Dental Council. Perhaps I should point out that plans to include in the registration system primary care providers such as dentists were consulted upon in spring 2008, and the majority of respondents supported the decision-including the British Dental Association.

In view of the shortage of time, I will write to my noble friend about the HTM 01-05 guidance, because there is rather a lot to say about that. I have convinced myself in the past fortnight that we are on the right path. I know that there is a lot of concern among dentists about cost, but I believe and have been persuaded that the guidance is the correct way to go.

Primary care is the bedrock of the NHS. It provides some excellent services but is capable of so much more. The balance of power within the NHS will undergo a fundamental shift-away from central control and away from restricted provision. The noble Lord, Lord Mawson, asked: who will lead? It is probably obvious from what I have said that, above all, we want clinicians and professionals rather than the politicians to lead. My noble friend Lord Alderdice spoke powerfully about that. We will give the NHS the freedom to innovate and a mandate to achieve excellence. We need a new can-do and should-do attitude. We need a dramatic improvement in productivity and efficiency. Most important of all, we need to see a significant improvement in the health and well-being of patients.

Photo of Lord Mawson Lord Mawson Crossbench 4:39 pm, 24th June 2010

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.

Motion withdrawn.

House adjourned at 4.43 pm.