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NHS: Front-line and Specialised Services — Debate

– in the House of Lords at 4:35 pm on 13th January 2011.

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Photo of Lord Turnberg Lord Turnberg Labour 4:35 pm, 13th January 2011

To ask Her Majesty's Government what steps they are taking to ensure that the proposed changes to the National Health Service will not damage front-line and specialised services.

Photo of Lord Turnberg Lord Turnberg Labour

My Lords, I suspect that your Lordships may feel that we have had rather a surfeit of debates on the NHS of late, and we have not even seen the Bill yet. However, I am pleased to open this debate as it gives us an opportunity to reflect on what the Minister has said in his previous responses and to try to be constructive in preparing for the Bill.

I should express my interests again as someone who has spent most of his working life in the NHS as a physician and professor of medicine and then as president of the Royal College of Physicians and more recently as scientific adviser to the Association of Medical Research Charities. I am pleased that the noble Baroness, Lady Jolly, will make her maiden speech in this debate. I very much look forward to hearing what she has to say.

In our previous debates a large number of criticisms of the White Paper came up, ranging from the wide extent of the proposed changes and whether they were proportionate to the perceived problems of an NHS of which many noble Lords extol the virtues, to a sense that a damaging commercialisation was creeping in. I have to admit that the previous Government were not immune from reorganisation and re-reorganisation zeal but it is significant that it was only when there was a clear increase in funding and a remarkable rise in the number of nurses and doctors that we saw a real improvement in patient care. So while reorganisations may be necessary at times, it is money that talks. At a time when we will be seeing retrenchment in the service, we must ensure that we do not cut these front-line staff.

I imagine that the Minister is aware of the study carried out by Sir Brian Jarman a few years ago in which he showed that there was a strong negative correlation between the number of doctors in a hospital and the mortality rate in that hospital-the more doctors, the lower the death rate. In that light, are there to be any cuts in the number of trainee doctors in the near future?

I shall mention three specific topics that impinge on front-line services: the pathfinder consortia; integrated services; and research and teaching. The pathfinders should generate a lot of valuable information. Leaving aside the bias that is introduced by the fact that this is a group of self-selecting enthusiasts who may not represent the generality of somewhat disinterested GPs, the data they will produce should be extremely helpful in deciding which paths to go down and which to avoid. After all, that is what I understand by the term "pathfinder".

So my questions for the noble Earl are, first, will the Department of Health collect information that will help in the design and size of the generality of consortia when they are rolled out? Secondly, what sort of information will be used in this assessment? Will they be those easy to measure data such as waiting lists or waiting times which at best are relevant only to patients needing cold surgery, such as hip operations, but not relevant to the majority of patients you find in hospitals who are usually brought in as emergencies, such as those with heart attacks, strokes or collapses of various sorts? Or will they try to get information on outcomes that are more meaningful for patients, such as how well they were treated as individuals, how quickly they felt better and whether they got back to work, or whether smoking cessation measures have been more successful, how well alcohol reduction programmes are working and whether all these sorts of outcomes are better under the new arrangements? There is a very welcome emphasis on outcomes in the Government's strategy for cancer, published yesterday. I ask the noble Earl whether a similar approach is intended for the many non-cancer patients faced by the consortia. Many of these outcomes need long-term study, but how else are we going to know whether we are doing any good by these changes. Will the department gather the type of information that can let us know which pathfinders to follow and which to avoid?

I return to the issue of integrated care that everyone-the royal colleges, the BMA, and the King's Fund-see as the most effective way in which services should be designed and delivered. By integrated care, I mean integration not only across primary care and social services but right across the spectrum, from the community to the secondary care sector where so much of the costs are to be found. You have only to see an elderly patient lingering unnecessarily in an expensive and potentially dangerous hospital bed because of a lack of facilities in the community to recognise the importance of integration of care.

Problems are due not only to lack of facilities, but are equally likely to be due to poor communication between the two parts of what should be a seamless service. It is patients with complex, multiple diseases, who form the majority and need seamless, joined-up, care across all three sectors. There are plenty of excellent guidelines to best practice for all these types of patients. The guidelines come from the royal colleges, specialist societies, medical research charities and a variety of other organisations. These guidelines are ripe for adoption by consortia for their contracts. One of the problems in the current NHS has been the slow take-up and implementation of good practice guidance. An obvious example is the national service framework for the care of stroke patients, published a decade ago and not yet fully implemented everywhere. What efforts will be made to encourage the spread of good practice, and how will that be incorporated into contracts by consortia? How will consortia use the expertise and knowledge of clinicians in secondary care and of front-line staff in the community sector? They should be working closely together. How will they overcome the potential barriers to this type of collaboration by the competitive environment and the "any willing provider" concept?

I want to say something about localism and its impact on research. In previous debates, the Minister was reassuringly clear about his commitment to research in the NHS, and the relative protection of the NHS research budget is of course very welcome. I congratulate the noble Earl and Dame Sally Davies for their efforts in achieving this. In this respect, what is to happen to OSCHR, the Office for Strategic Co-ordination of Health Research, the body set up to help co-ordinate research funding between the MRC and the NHS?

My main concern here is the role of GPs and the consortia in commissioning research and teaching. A recent survey by the Association of Medical Research Charities and Involve found that the vast majority of patients were happy to give consent for the use of their personal data for research, but that few GPs were interested in research, and that even the fairly straightforward business of seeking consent from patients was regarded by many as difficult and too time consuming. Therefore, if GPs are to have a key role in NHS research, it will be vital to give them some sort of incentive for their involvement. I should be very interested in hearing more from the noble Earl about how he thinks we might provide this stimulus.

Finally on research, I expect that the Minister will have seen the excellent recent report from the Academy of Medical Sciences, commissioned by his department, on the regulation of research. Is it his expectation that the Government will accept the recommendations in the report, particularly those relevant to streamlining regulation?

I hope I have been a little more constructive today and I look forward to the contributions of other noble Lords and, of course, to the response from the noble Earl.

Photo of Lord Colwyn Lord Colwyn Deputy Chairman of Committees, Deputy Speaker (Lords) 4:45 pm, 13th January 2011

My Lords, I congratulate the noble Lord, Lord Turnberg, on securing the debate and on his knowledgeable contribution. It was a privilege for me to work with him for a number of years at the Medical Protection Society.

I am delighted to be so far up the list this afternoon, although I am not sure if it is an advantage. I was given the number 2 slot in the last debate on health on 16 December and failed to excite the Minister with my questions. He has now kindly been in touch to tell me that there is a letter in my box. I am aware of the tremendous pressure that he must be under. I also failed to make an impression at Question Time earlier today and will make a comment on the regulation of herbal practitioners at the end of my few remarks, which will inevitably concern the dental aspects of front-line and specialised services.

NHS dentistry's place in the health reforms is unusual. As well as being subject to a change in commissioning arrangements, with responsibility for primary care dentistry being transferred from primary care trusts to the new national commissioning board, dentistry will undergo a parallel overhaul of the way it works, with completely new contractual arrangements being developed. This is a pivotal time for NHS dentistry, in which the mistakes of the previous Government's 2006 reforms can be rectified. It will be vital that our reforms engage the dental professionals who will deliver care under the new system, and I am pleased to say that the British Dental Association has offered its broad support to two important parts of the reforms. The decision to transfer responsibility for commissioning from PCTs to the new national commissioning board has been viewed positively by the profession. Given the problems and inconsistencies witnessed under PCT commissioning, that is unsurprising. Dentists have also been positive about the reforms to the dental contract that the coalition Government are undertaking. These reforms build on the work of Professor Jimmy Steele, whose critical report on the current system has produced a vision of a better system. Pilots will begin in April to develop this.

On the face of it, dentistry looks to have a bright future. The risks inherent in changing systems and commissioning arrangements simultaneously were highlighted by Labour's reforms in 2006, when the ability of PCTs to manage the introduction of the new dental contract was undermined by a reorganisation of primary care trusts that saw their number halved. The success of the coalition Government's reform of dentistry will depend on having the right people in place to manage change at an early stage of the reform process. It will also require a balance to be struck between central commissioning and engaging the local expertise of bodies such as local dental committees and figures such as consultants in dental public health.

Dental public health is an important issue in its own right, and ensuring that dental public health expertise inputs into new arrangements and is integral to the wider reform of public health will also influence the success of the reform of dental care. This House needs assurance that the Government plan to utilise those local dental experts in the new commissioning arrangements.

Another lesson we must learn from the 2006 reforms is the importance of properly testing elements of reform. Two major parts of those reforms, the revised patient charges and the system of units of dental activity by which dentists' work is measured, were not piloted in the lead-up to April 2006. As I said, pilots for the new reforms will commence in April. They will test different models that will include patient registration, quality and capitation. The models are intended to lead to a new dental contract that will facilitate a more preventive approach to dental care. The pilots must be given time, they must be properly evaluated and their lessons must be learnt in dialogue with the dental profession.

The Government will need to tread carefully as they pursue each of these reforms, ensuring that a co-ordinated approach to dentistry is taken across all departments within the Department of Health. They must manage the various strands of reform that will contribute to the creation of new arrangements for primary care dentistry in England. What guarantees will the Minister provide that the work on the three strands that will impact on the delivery of primary dental care-the new contract, public health and commissioning arrangements-will be joined up and co-ordinated?

I conclude with a question that I was unable to ask earlier today. Will my noble friend offer any encouragement to patients and to the practitioners who use herbal medicine and who regard regulation-as recommended in November 2000 by the Walton committee, of which I was a member, and the Pittilo independent report set up by the Department of Health-as vital to the practice and continuation of their profession?

Photo of Baroness Sharp of Guildford Baroness Sharp of Guildford Liberal Democrat 4:50 pm, 13th January 2011

My Lords, I, too, thank the noble Lord, Lord Turnberg, for initiating this timely short debate, and I also look forward to the maiden speech of my noble friend Lady Jolly.

As most noble Lords will know, it is not usual for me to speak on National Health Service issues. I do not have the detailed knowledge that I have of the education system, but I retain an open mind about the proposed changes. I come from Surrey where we have not had a very happy experience with PCTs. Our PCT has had perennial financial problems of one sort or another. One area with which I have some concern is the future of community hospitals. The decisions they have made have been bad and incredibly vacillating, and have taken far too long. By contrast I have had good experience with my GP practice, and most of my friends are also extremely happy with their GPs. My own practice is very innovative and go-ahead, and I am pleased at the thought that it will have more power.

Of the reforms, I welcome very much the greater local accountability. We on the Liberal Democrat Benches have long argued for bringing together the responsibilities for health and social care, and a greater role for local authorities. The creation of the health and well-being boards will bring together, within the NHS, both the social care and the related children's care and public health services. That is a very important step in helping to provide us with joined-up health services. I also welcome the focus on patients and their needs. I hope that it will not just be rhetoric. In most cases, patients defer to decisions made by their own GPs or by the consultants they see, but there is a danger that the whole system may be too dominated by professionals and the mentality that professionals know best what to do. It is, therefore, extremely important that we retain within the various boards lay membership at all levels-in the GP consortia and all the way up to the NHS commissioning board.

Lastly, I welcome the establishment of HealthWatch. I was quite involved at one point with our local community health council and I regretted very much its replacement 10 years back by what struck me as a relatively toothless link committee. I hope that HealthWatch, together with local scrutiny committees, will mean that there is a genuine watchdog for the patient in terms of quality and accountability.

I have five questions for the Minister. First, precisely what is the role and what will be the powers of the NHS commissioning board? Secondly, where within the system does NICE now fit? I am grateful for reassurances from the Minister at a meeting the other day that NICE will not be abolished, but indeed would be strengthened. However, it would be useful if those reassurances were on the record and he could tell the House how it will fit into the greater scheme of things. Thirdly, I do not understand the trail of accountability in the new system. Who will set the budget for the GP consortia and who will oversee their expenditures? What happens if they overspend? Who holds them to account? With the strategic health authorities now going, who will oversee hospital expenditures and hold them to account if they overspend? While I welcome the bringing together of local public health services with the community and children's health services, will there be enough resources to meet needs given the cuts in local authority funding? Already instances of bed-blocking are reappearing. My noble friend John Shipley raised the issue of bed-blocking in Newcastle with the Minister the other day and there are other instances. As a school governor I have experience of children's and adolescent mental health services and the lack of facilities to provide educational psychologists when they are needed to back up special educational needs provision in schools. Time and again, the NHS has failed to deliver on its responsibilities. How are we to get really effective linking-up between health and local government services?

Finally, the health and well-being boards will bring together public health and social care services, but one of the traditional problems of the NHS has been the divide between primary and secondary care. What incentives are there within the system to improve that relationship? In particular, there is the relationship between GP care and specialist care. Can the Minister tell us a little more about proposals there? I look forward to hearing the answers that the Minister will give us on those issues.

Photo of Baroness Masham of Ilton Baroness Masham of Ilton Crossbench 4:55 pm, 13th January 2011

My Lords, I thank the noble Lord, Lord Turnberg, for introducing this important debate. It is important because there are so many concerned people who fear, with the spending cuts, that some of their vital specialised services, which are lifelines, may be severed. I hope that the noble Earl can allay some of those fears.

I must declare an interest, as I am president and founder of the Spinal Injuries Association. There is hardly anything more catastrophic than breaking one's neck and finding that you are paralysed from that point down. It is bad enough breaking one's back, but in all cases there can be complications, and specialised treatment is vital, otherwise complications occur, leading to human suffering and unnecessary costs for the NHS.

With this huge reorganisation, perhaps there is a chance to improve some front-line services and the specialised services. The White Paper states that patients should be central to the NHS. Are those just words, or will there be action? Will the Government listen to patients, patients' groups, and their doctors? There should be shared decision-making-nothing about me without me.

We were once the leading country in the world in the treatment of spinal cord injured patients. All of us with an interest in the subject would like that specialty to be returned to its former glory. Doctors, nurses and physiotherapists would come to our national centre from all over the world to train. We are concerned that, already, some expert consultants have retired, and more are to go. Therefore, I ask the Minister a few questions, which perhaps he can answer by letter.

Are there plans to reinstate spinal cord injury medicine as a speciality or subspecialty? The specialty status was lost in 1995 as a result of the alignment with European regulations. That has resulted in considerable loss of appeal and skills. Are there plans to create a national register, a database, for spinal cord patients? Do the Government know whether current trainees will be able to continue the same services offered by retiring consultants in spinal cord injuries? Is there adequate capacity to meet the readmission needs of spinal cord injured patients to spinal cord injury centres? I do not think so.

Are your Lordships aware that there are more than 9,000 new cases of tuberculosis in the United Kingdom every year? In the UK, the number of deaths from TB is 1.5 times higher than the number of deaths from HIV/AIDS. London has the highest TB rate of any major capital city in western Europe. Prevention is vital. I consider it a front-line service. The Find & Treat team, which runs the mobile x-ray unit, focuses on screening groups in London with social risk factors, especially the homeless with TB. Homelessness is a risk factor for multidrug-resistant tuberculosis. That underlines the importance of ensuring that complex cases are detected early and supported to successfully complete treatment.

The emergence of extensively drug-resistant tuberculosis threatens to make the disease untreatable. The Find & Treat team is excellent, and I hope funding can be found so that it can continue its valuable work.

Childhood cancer and leukaemia are rare conditions that require complex and highly skilled diagnostic and treatment services to achieve the best outcomes. Without specialised, centralised cancer care and excellent front-line local paediatric services, there is a risk that not all children with curable diseases will be cured. These services must be safeguarded, built on and improved.

Photo of The Bishop of Gloucester The Bishop of Gloucester Bishop 5:00 pm, 13th January 2011

My Lords, I speak as until recently the chair of the Church of England's Hospital Chaplaincies Council, and, as it happens, the husband of a specialist in palliative medicine and the father of a fairly newly qualified hospital doctor. I believe passionately in the National Health Service and want to see its future secure.

I share some of the concerns expressed recently by primary care trusts about what might be endangered by their demise and by my own church's response to the Government's proposals through its mission and public affairs council, and I hope these concerns are among the issues that the Minister will want to address. There is time to do little more than list them.

First, there is in the proposals a risk of losing local intelligence and grip on performance in the management of poorly performing doctors and practices. Secondly, there is a lack of clarity about future commissioning arrangements for learning disability services, mental services and services for other vulnerable groups. Thirdly, the White Paper does not consider what additional GP training might be needed to make effective patient-centred services a reality. In the absence of training and monitoring, it would be all too easy to see the provision of patient-centred services being reduced to a box-ticking exercise. Fourthly, the proposals do not make it clear which services are considered to be front-line services and which are ancillary or administrative. In seeking to cut administrative costs, both commissioners and providers may find themselves under pressure with regard to allied health professionals and chaplaincy services, yet holistic care is essential for good health outcomes; the expertise of allied health professionals and chaplains ought not to be minimised in delivering such care. Fifthly, and perhaps more fundamentally, there is a question about the ability of local authorities to take on new responsibilities in the face of 20 per cent cuts in their own budgets. Linked with this is the complexity of what is proposed, with GP consortia responsible for commissioning healthcare, local authorities receiving an enhanced role in relation to public health and health and well-being boards also having a part to play. The fact that GP consortia and local authorities are not coterminous will make the commissioning process more difficult.

Alongside these worries, I make two other points very briefly. The first is that for the new arrangements to work, there needs to be rising morale in the health service. That cannot happen while there is a culture that is dismissive of the achievements of recent years. It may well be right, for instance, for PCTs to disappear, but their work does not need to be criticised or rubbished. Unlike the experience of the noble Baroness, Lady Sharp, in Surrey in Gloucestershire where I live and work, the PCT has brought about transformation in infrastructure with new buildings, in finance with historical debts resolved, in health outcomes, for instance in the reduction of teenage pregnancies, and in engagement with clinicians and communities. We need to affirm and honour those who work in the NHS, or else the quality of the health service could trickle through our fingers as morale dips at the same time as difficulty climbs.

Finally, we need more honesty and realism. Changes are almost bound to damage front-line and specialised services. We have to save money. We have to make choices. We need to accept that not everything can be delivered. If we can start being honest about that, there can be genuine debate about priorities and proper consideration of what can and cannot be achieved. Instead, and this contributes to the collapse of morale, we keep up a pretence that cuts need not damage services and we expect those who work in the NHS to deliver the impossible, but they cannot.

Photo of Lord Winston Lord Winston Labour 5:05 pm, 13th January 2011

My Lords, back in November, when I had just come back from cycling around Beijing and seeing at first hand the health service in China, I spoke later that day in a similar debate when the noble Earl, Lord Howe, admonished me for being somewhat acerbic in my comments about the health service. I hope that he has forgiven me, because I think a combination of my jet lag, my passion for the health service-like his passion for the health service, which I greatly respect-and the anxiety that one sometimes feels when speaking from these Benches, and for me the unusual taste of being very briefly on the Front Bench, resulted in my being rather stronger in my remarks than perhaps I should have been. I would, however, like to ask him some questions about the third issue that the noble Lord, Lord Turnberg, has produced in his debate, and I congratulate him on introducing it. May I also say what a pleasure it is to see that the noble Baroness, Lady Jolly, has put her name down to make her maiden speech in this debate? We look forward to hearing her in just a moment.

Noble Lords must forgive me if I concentrate on hospital medicine, but that is the area I know best. I remember many years ago, from my experience in the United States-when I was a visiting professor in Baltimore and Boston, and later in Texas-that the Americans were very surprised at the massive surgical experience that we could gain in the health service in this country because of the way in which the service was run. We could centralise many specialised services and do very advanced work that was both innovative and useful for research. One issue is that, while this has been more difficult since the introduction of the internal market, there have been at least some attempts to get back to doing exactly that.

Many aspects are really important for centralisation. First of all, that kind of centralisation is best for some patients with particular needs if they can travel to a service. That often means that they are going to get the best medicine. It is a question not of patient choice but of making sure that they get the best treatment from the most qualified people. Secondly, that kind of centralisation is ideal as a pull for teaching. It is also excellent-indeed, some people would say essential-for training people to make sure that we get the best surgeons. It is a problem that the noble Earl, Lord Howe is very conscious of, given the changes that have happened as a result not of the NHS but of European pressures, which have made things more difficult.

Centralisation is also important for innovation. The key issue is how these expected changes in the health service will affect our excellence in research. What I really want is reassurance from the noble Earl that the sorts of things that were developed in the health service hitherto will not be difficult to achieve under the current proposals in the White Paper. For example, it seems impossible to imagine that in vitro fertilisation could develop as a research procedure in the structure as proposed. Certainly, during my time at Hammersmith, I saw by-pass surgery, transplant surgery and the cancer smear test being developed, and many other examples of innovative surgery and medicine. Many of the great institutions, such as Great Ormond Street, Hammersmith, and some in Liverpool, Manchester and elsewhere have been made great and international because they have been able to function in a way that it is difficult to see will continue under the structure in this White Paper. I want to make certain that the Minister agrees-I know he does-that the jewel in our crown is the National Health Service. A very special aspect of that, which is internationally recognised, is the unique nature of academic medicine in this country. I would like him to tell us how academic medicine will be protected and will flourish in the structure of the White Paper.

Photo of Baroness Jolly Baroness Jolly Liberal Democrat 5:09 pm, 13th January 2011

My Lords, I start by thanking noble Lords kindly for the warm welcome that I have found since my introduction on Tuesday-from Members opposite as well as from my own Benches. Advice about my speech was to keep it simple, but most of all to keep it short. I extend these thanks to members of staff who have been exceptionally helpful in all manner of ways. I must say that I am not without trepidation. My introduction by comparison was easy, as once in my robes I was but an actor. Today, I feel somewhat naked without them, particularly in such eminent company.

I live in Cornwall in a community of some six or seven houses overlooking Bodmin Moor. We have little choice in our services. We use them where we can find them and so rely on them all to be excellent, as the noble Lord, Lord Winston, said. Disappointment is rare. My sponsors, my noble friends Lord Tyler and Lord Teverson, have both left their mark on Cornwall, and I am delighted that today another friend of Cornwall was introduced-my noble friend Lord Marks of Henley-on-Thames. The bottom left-hand corner may be far away, but in this place it will not be forgotten.

I trained as a control engineer, taught maths for 15 years, and spent time living and working in the Gulf. On coming home, I joined an NHS trust board. Some years later, a couple of NHS reorganisations found me chairing a Cornish PCT and managing a budget of £120 million. Recently, I have been working for Macmillan Cancer Support, a charity dedicated to providing excellent services to those whose lives are affected by cancer, as well as for a campaigning organisation on issues as varied as fuel poverty and survivorship. It was difficult delivering services in such a rural environment, especially ensuring that services are linked as seamlessly as possible with our social services. Not a year went by when we did not have to find savings to be passed on to services.

In the past, my family has had brief engagements with the NHS, but it was not until last November when my father had a heart attack that I saw the NHS in action for real, for one of mine. One evening, he went to bed feeling unwell. We called NHS Direct. It called an ambulance, which was with us in 15 minutes. After a half-hour dash he was admitted directly to the South West Cardiothoracic Centre in Plymouth. His ECG had been e-mailed ahead by the ambulance crew and he was met by a team called in on a Saturday night. Led by Dr Haywood, his team was professional, caring and candid. The ward really resembled the bridge from the starship "Enterprise", but it was here too that I heard talk of patient dignity and advocacy. My father mattered, as did my mother-a lady who will be 90 on her next birthday.

Cornwall still has a network of community hospitals that allows patients to be treated nearer their homes, relieves beds in the pressured acute units and prepares patients to return home. In time, at my local community hospital in Launceston, I saw at first hand social services working with the ward team, the physio and occupational therapists. The patient came first and together they got my Dad home. Sadly, the NHS was no match finally for age and frailty. He died one month ago today. We saw the NHS at its finest, from the highest of high-tech medicine to the best of nursing care, working seamlessly across four NHS organisations and social services.

In the PCT our decisions involved executive directors, non-executive directors and, most importantly, health professionals. We were committed to a comprehensive service that is available to all, free at the point of use and based on need and not on the ability to pay. We took into consideration local issues-rurality, sparcity, atypical demographics and huge population increases in the summer. We did not run or commission services in the same way in Cornwall as they are here in the capital.

In conclusion, the points made by the noble Lord, Lord Turnberg, are well made. I would add that in reframing the NHS, I trust that the noble Earl will give every care and consideration to service delivery and, more importantly, to appropriate and adequate funding for far-flung remote rural areas, such as Cornwall.

Photo of Baroness Finlay of Llandaff Baroness Finlay of Llandaff Crossbench 5:15 pm, 13th January 2011

My Lords, I am delighted to follow the noble Baroness, Lady Jolly. I welcome her and congratulate her on having made a superb short maiden speech in the time available. She has shown a deep affection and critical praise of the NHS. She brings to us experience from engineering and maths, and the critical thinking from that, as well as extensive personal, administrative and provision experience in the NHS and the voluntary sector. I am sure the Liberal Democrats celebrate her being on their Benches, and we must celebrate her addition to this House.

I speak as a clinician in the NHS, and declare all those interests in so doing. The Government have inherited much from the previous Government. They have inherited the problem of the PFI burden, with high interest rates that will increase the burden on hospitals. This will not go away during reorganisation. They have also inherited, as the noble Baroness, Lady Jolly, has illustrated, very high levels of satisfaction with the NHS as we know it. In 2009, indeed, 64 per cent of the population declared themselves to be satisfied or very satisfied. Even among Conservative voters, the figure was 61 per cent.

The public out there fear the loss of the NHS. They fear the escalating costs that they see in US healthcare. A major concern is the concept of "any willing provider" and its effect on primary and secondary care. The competition engendered by this concept seems to work against collaboration. In private-provider competition there seem to be three main problems. The first one, identified in the US, is fraud. The biggest department in the FBI is that which investigates fraud in healthcare, yet we have US providers advising us. I find that worrying. The second problem concerns the role of Monitor. Will Monitor promote competition? The US system and others show that health outcomes are better where collaboration is higher. I ask the Minister why collaboration between primary and secondary care is not the key marker rather than a pre-requirement to competition. The third problem relates to European law. Current law on services of general intent allow subsidiarity for publicly provided healthcare, but if it is privately provided it will become subject to general interest regulations. If the reorganisation fails, can the service effectively be renationalised?

I turn briefly to financial failure. Current legislation allows for a failing foundation trust to be brought back into public administration, but that will be repealed. What will happen if a GP consortium runs out of money? Will the patients be left with less or no care? I understand that there is to be a central levy to allow for failure. I ask the Minister how it was calculated, and whether the Government are confident that it will be enough to continue care provision, particularly if faced with multiple failures at the end of the financial year. If a GP consortium fails, will it be taken over by the private sector, as is happening with hospitals?

The NHS is there for patients. The phrase "nothing about me without me" is both clever and wholly appropriate, referring to clear simple terms of informed consent, but when transposed to choices in healthcare provider it can become distorted rhetoric. The choices that people have to make relate to decisions across all parts of care: whether to remain at home when ill; whether to have a gastrostomy, as swallowing fails in neurological disease; or whether to try physiotherapy to defer joint replacement surgery. There are decisions about immunisation versus infection risks and about how to manage psychotic disease relapse.

These decisions depend on services being integrated, not operating in isolation or in competition. They require excellence in clinical standards, not just "any willing provider". The problem is that private providers can cherry-pick services to provide in neat packages, but most patients do not fit neat packages. Choice in packages requires a surplus to choose from, but we cannot afford that. Those with complex co-morbidities are optimally managed by a service leading their care and collaborating with others, avoiding duplication and minimising the risk of patients falling into a gap.

How will secondary care integration with primary care be promoted and long-term planning secured? Patients want choice to be seen by the right person at the right time. Pathfinder consortia may be achieving this in the short term, but if Monitor is to ensure competition, how will such collaboration continue? To ensure data on fair competition, will commercial confidentiality clauses be overturned by statute? How will outcome data be collated? Will they be meaningfully interpreted to account for those with multiple co-morbidities?

I ask the Minister these questions because we are embarking on a reorganisation that will cost up to £3 billion. There is a genuine fear that an integrated NHS is being dismantled under the influence of for-profit organisations.

Photo of Baroness Greengross Baroness Greengross Crossbench 5:21 pm, 13th January 2011

My Lords, as chair of the All-Party Group on Dementia, I have a particular interest in dementia care. In my brief remarks, I wish to highlight the potential impact of the changes to those services.

People with dementia are major beneficiaries of effective joined-up working between health and social care. Can the Minister assure me that any changes in the current coterminosity of boundaries for commissioning health and social care will be appropriately managed for people with dementia?

One in three people over the age of 65 will die with dementia, and so for many it will be a terminal disease. Why, therefore, is dementia treated, rather than as a health issue like cancer, more as a social ill? In other words, it is more likely to get funding through social care. Thus many dementia patients are obliged to self-fund their care. Is something going to be done to remedy that?

With the implementation of the national dementia strategy we have witnessed the increasing knowledge and ability of many NHS managers in commissioning for dementia, which is absolutely essential. However, the number of people with these particular skills remains relatively small and it is a concern that the pace of structural change has the potential to undermine this progress. Can the Minister assure me that the valuable dementia commissioning expertise which has been developing recently will be retained in the system?

Lastly, GPs will in future play an increasingly important role in commissioning services for people with dementia. However, I am concerned that many GPs have too little awareness or knowledge of dementia. For example, when surveyed, only 31 per cent of GPs believed that they had received sufficient basic and post-qualification training to diagnose and manage dementia and only 47 per cent of GPs said that they had sufficient training in dementia management. Only one third of people receive a formal diagnosis of dementia. What will be done to ensure that GPs are fully capable of discharging their new commissioning responsibilities with regard to this absolutely urgent situation? I hope that the noble Earl can respond.

Photo of Lord Touhig Lord Touhig Labour 5:24 pm, 13th January 2011

My Lords, I am pleased to be here for this debate, if only to have listened to the speech of the noble Baroness, Lady Jolly, because she spoke from the heart about the National Health Service and her family's personal understanding of and reception by the NHS recently. She was also able to speak with some authority as someone who has been involved in the provision of healthcare. I look forward to her future contributions on this matter.

I am delighted to follow the noble Baroness, Lady Greengross, because I, too, want to relate my remarks to dementia. She does a tremendous job in chairing and leading the all party group.

If you are a man who has had a stroke and as a result you have no recollection of the wife you have been married to for 30 years, and then you develop dementia, you have no voice. If you are a woman who one day stops talking to her family and has not spoken a word in 18 months, retreating into a valley of silence, you have no voice. If you are a dementia sufferer who is doubly incontinent and you have no downstairs shower and toilet, and the only day of the week when you can be sure that you will be made really clean is the day you go to a healthcare centre, you have no voice. As Parliament, at the behest of the Government, prepares for a major shake-up in the provision of NHS services, I believe that we must be the voice for dementia sufferers and their carers.

Three-quarters of a million of our fellow citizens have dementia and it is forecast that by 2025 the number will be over a million. I welcome the success of my noble friend Lord Turnberg in securing this debate so we can press the Government to tell us how front-line specialist services will be protected in this shake-up. We currently spend £20 billion a year on dementia and, as the noble Baroness, Lady Greengross, pointed out, one in three people over the age of 65 will die with dementia-yet currently only one in three receives a formal diagnosis. As a member of the Public Accounts Committee in the other place, I well remember a National Audit Office report in 2007 which found that money was being wasted on poor quality care. The report went on to say that rates of diagnosis were low, cost-effective interventions were not widely available, and health and social services were often disjointed and inefficient. A further NAO report this year said that the National Dementia Strategy for England, first published in 2009, was comprehensive and ambitious. It found that there was early progress towards implementation, but warned that not enough priority was being given to dementia. There has been some progress, but not enough.

I share the worries of the Alzheimer's Society, which is concerned that the pace of structural change that is going to come in the NHS has the potential to undermine the progress we have made so far. That is all the more reason why these changes, as the noble Baroness, Lady Greengross, said, have to be managed very carefully indeed. When I was a Minister in the previous Government, I well remember the former Prime Minister, Tony Blair, saying to me that for him healthcare was not about the doctor, the nurse or the latest high-tech scanner, it was about the patient. Of course, he said, we need the doctor, the nurse and the high-tech scanner, but the focus the whole time must be on the patient-and that, I believe, is right.

Over the past couple of years, we have seen increasing knowledge and ability among many NHS commissioning managers in commissioning better and improved care for dementia. However, the number of people with these particular skills is relatively small. It is vital, therefore, that the pace of structural change which will come about as a result of the Government's NHS changes does not undermine this progress. Valuable dementia commissioning has been developed and must be retained. Perhaps the Minister can say something about this. GP commissioning will play a major role in the future, but only 31 per cent of GPs believe they have received sufficient basic and post-qualification training to diagnose and manage dementia. Can the Minister say what specific steps the Government will take to ensure that the small pool of dementia care commissioning expertise is not lost, a point well made by the noble Baroness, Lady Greengross?

A recent survey showed that only 5 per cent of GPs had discussed the national dementia strategy with their PCT commissioners. What is important, therefore, is that the current coterminosity of boundaries for commissioning health and social care is not lost. People with dementia are major beneficiaries of effective joined-up working between the NHS and social care because they use the two services. In order to continue to meet the needs of people with dementia and their carers, can the Minister assure us that the new GP commissioning arrangements will result in a comprehensive primary care response, including improved home care, so that admission to the acute sector is used only where it is necessary?

We can only imagine what it must be like to suffer with dementia. A dementia sufferer is like a prisoner locked away by an illness of the mind in a world of their own. That is why we must be the voice for those people and their carers.

Photo of Lord Kakkar Lord Kakkar Crossbench 5:30 pm, 13th January 2011

My Lords, like other noble Lords, I first congratulate the noble Lord, Lord Turnberg, on having secured this important debate and the noble Baroness, Lady Jolly, on a marvellous maiden speech, which was very moving. I also declare my own interest as a clinical academic practising surgeon and my role in the NHS Staff College at University College London Partners.

The question posed by the noble Lord in this debate is an important one. He asks what steps are currently being taken to ensure that front-line and specialist services are not undermined as we move towards the changes proposed in the forthcoming health Bill. Healthcare systems around the world, particularly mature healthcare systems, are all focusing on the need to improve quality and value, so that the very best clinical outcomes can be achieved for our patients and that these can be achieved in the most effective and cost-efficient fashion so that the valuable resources that the state provides for healthcare are used for the maximum benefit of all in society.

In that regard, there are four important actions that might be considered in the interim between now and when any changes that are finally agreed when the health Bill passes through this Parliament come into force. The first is in the area of the education of general practitioners and other clinicians in primary care who will have to play a greater role in commissioning. At the moment, there is no specific training for the skills that will be required to ensure that, at the very least, they can supervise and provide the appropriate governance for any commissioning taking place in the environments where they have responsibility in primary care. I ask the noble Earl what arrangements are being made currently to ensure that programmes of continuing professional development start to come into place to provide the skills to those working in general practice to prepare them for the new responsibilities that they will inevitably have if practice-based commissioning goes forward.

The second is an area that the noble Lord, Lord Turnberg, has alluded to-the whole question of integrated care pathways. These are important. In ensuring that we maximise quality and value in healthcare systems, it is well recognised that a focus on integrated care pathways, particularly for chronic diseases, will be essential. To ensure that we can provide the opportunity for informed commissioning of these services, we need to be certain that metrics that can be used to determine whether the clinical outcomes are successful and are providing best value are developed, assessed and then are available for those who will take commissioning decisions in the future. What arrangements are being made currently to start developing models of integrated care, particularly for chronic diseases? What work is being done to determine the appropriate outcome measures and metrics that might be used to drive commissioning decisions in the future?

The third area is one of specialist services and in particular the important question that has been raised about the tariffs and the current difference in costs for the provision of specialist services. With the move for responsibility for specialist commissioning to the NHS Commissioning Board, is work currently being undertaken to provide clear definitions of what specialist services will be in the future? For those delivered at regional or supra regional level, what will be expected of these specialist services? Is work being undertaken to determine what costs and tariff base will be required in the future to ensure that these specialist services are not undermined in the changed commissioning arrangements? In particular, will the institutions that provide these specialist services remain sustainable in the altered commissioning environment?

Finally, I turn to the issue of clinical leadership, one that I have spoken about previously in your Lordships' House. There is no doubt that that this is a major programme of change. It is often said that it is only those who deliver the service who can change the service. Our healthcare professionals, be they doctors, nurses or other healthcare professionals, will not be managed into this change: they will need to be led into it. Winston Churchill said some 60 years ago in a famous speech:

"Give them the tools and they will finish the job".

I strongly believe that if we give our healthcare professionals effective clinical leadership, they will indeed deliver for us the change agenda of improving quality and value as well as these changes and those that the previous Government quite rightly focused on, so that we can continue to enjoy a National Health Service of which we are all proud, which delivers the very best healthcare for the people of our country.

Photo of Lord Crisp Lord Crisp Crossbench 5:35 pm, 13th January 2011

My Lords, I am grateful to the noble Lord, Lord Turnberg, for giving us an early run at one of the key questions coming out from the Government's proposals-a question which I might rephrase as: will they work where it really matters, at the front line? I, too, congratulate the noble Baroness, Lady Jolly, for giving us such an eloquent description of why they matter.

There is a great deal to be said for the Government's proposals-not least the continuation of a 20-plus year policy for a primary care-led NHS and for decentralisation, although, as some noble Lords have pointed out, there need to be limits to both of those. There are of course risks. It will be no surprise that I shall concentrate on the more managerial issues. The Minister knows, but I should say for the record, that I was chief executive of the NHS and Permanent Secretary of the Department of Health for six years; so I am afraid that I know a bit about reorganisations and may be seen by some of my clinical friends in the House as one of the villains of the piece.

I read the Command Paper that came out before Christmas with great interest, particularly where it talked about how to manage the transition. It was well written, as I would expect from former colleagues in the Department of Health, but there were some fundamental gaps that are fundamental risks. I will mention three of them.

The first is the capability of consortia. I have no doubt that there any many good, talented and skilled GPs and people working in primary care who can and will take the lead in this area. I did not find anything in the paper that described how the capabilities of those consortia to discharge that role would be in any way tested. Your Lordships will no doubt know that foundation trusts and NHS trusts go through a critical scrutiny as to whether they are capable of discharging their functions, and that is to be continued under these proposals. As an NHS trust chief executive 15 years ago, I remember going through just such a tough process where people from outside the organisation tested whether our ambition to do something was matched by reality. The optimism of our will to do it was tested against the pessimism of whether we could actually deliver-were we up to the job? I do not know why that is not being put forward here for GPs unless the Government are too eager to get the GPs involved and do not want to frighten them off at that stage. It is important that some testing is done to secure the success of what is intended here. How will the department test the capability of consortia before they are given free reign?

Secondly, as a subset of that, I was again interested to know how consortia would be accountable. I see in the text that there is somebody called an accounting officer who is not really defined other than as the person who will account to the NHS commissioning board and then upwards to Parliament for the expenditure of the consortium. It need not be a doctor, we understand, but there is a question about what their responsibilities and powers are. In some ways it looks like going back to the old system of consensus management that we had 25 years ago where you basically had a doctor and an administrator in charge and you had to get the two of them to agree to get any change going. This was the sort of situation of which Roy Griffiths, in a report for the Conservative Government of the 1980s, said that, were Florence Nightingale back today, she would be wandering the corridors of the hospital wondering who was in charge. That question is still there. How will that arrangement work for accountability?

The third gap, to which my noble friend Lady Finlay alluded, is that these consortia will turn for expertise to private sector organisations, some of which will be from abroad. We know that GPs are saying that, and that it is already happening. They will, for example, turn to people with experience in insurance systems. We have a social contract system: we expect to be able to go to our doctor and know that they will do their best for us, looking at a comprehensive care with some exceptions rather than an insurance system that too often specifies what you can have. There is a big difference between the two. My worry is that there will be a change in the attitude of mind and behaviour in that relationship.

I have one positive suggestion here which the Minister may or may not like. Although there are pathfinders and there is preparation under way, I have not seen anything that suggests there will be any large-scale simulation of these proposals-getting people together and, over a period, encouraging them to play out the various roles to see what will happen. That has been done in the past, and it is an effective way. The question need not be whether these proposals will work but what you need to do to make sure they work as effectively as possible. Can the noble Earl say whether the Government propose to do any such simulation of these proposals before bringing them fully into effect?

Photo of Baroness Meacher Baroness Meacher Crossbench 5:41 pm, 13th January 2011

My Lords, I, too, applaud the noble Lord, Lord Turnberg, for initiating this debate. I am sorry that I was not aware of it until rather late in the day, hence my having been slotted into the gap. I must apologise to the House for that. I want to raise two questions which have perhaps received less attention than others. Before doing so, however, I want to set out two examples of the direct implications for services of organisational change. The first concerns the major rationalisation of the acute sector, particularly in London, which was inherited by this Government. The aim of that rationalisation was to reduce the considerable excess supply of hospital beds, particularly in London, in order to make the absolutely essential savings to enable the NHS to balance its books and to improve radically its productivity. These major changes have been put on hold awaiting the completion of the development of the GP consortia arrangements. The failure to make those rationally-argued changes in a timely manner will have direct implications for the funding of front-line services.

My second example is local. I am not in any way suggesting criticism of the organisation or individuals concerned, but the commissioning changes are already inevitably distracting managers from their day-to-day essential decisions, again with severe adverse consequences. A particular trust with which I am associated, and I declare an interest, has to cut its budget by 4 per cent each year for three years-by £10 million a year. To achieve that, two very significant rationalisations were evaluated and planned, but the PCT's approval is essential before we can go ahead. If those vital savings are delayed-and they are being delayed, as we will not have the PCT decision in time-then we will have to turn away from those well planned changes. The risk is that we will have to make quick cuts on front-line services. Those are my concerns about organisational change and its direct impact on front-line services.

I have two questions. The first concerns the planned removal of the power of the National Institute for Health and Clinical Excellence to determine whether a specific-

A noble Lord:

Two minutes.

Photo of Baroness Meacher Baroness Meacher Crossbench

Two minutes? I am sorry; nobody warned me about the two minutes. I will very quickly raise the questions. The first is about the power to determine whether a specific drug or treatment may be given under the NHS-I am now completely thrown, but there is a concern about the loss of that power of NICE. The second question concerns the role of Monitor as the regulator and the removal of its compliance framework under the new proposals, as I understand them. It is an excellent provision under the old system, which we are going to lose. I have concerns about that and look forward to the Minister's response.

Photo of Baroness Thornton Baroness Thornton Shadow Spokesperson (Health) 5:44 pm, 13th January 2011

My Lords, I congratulate my noble friend Lord Turnberg on this debate. Indeed, of all the speakers who have contributed today I particularly welcome the noble Baroness, Lady Jolly, to our debates and our deliberations for the future. I also need to congratulate all the speakers who have contributed today, because we have had a really excellent debate. We probably needed about two or three hours longer than we have had; maybe we need to do that.

I want to raise two matters, one strategic and one specific. Since June we have debated or had Questions on, among other things, cancer, diabetes, chronic pain, Parkinson's disease, epilepsy, social care, COPD, neurological conditions, dementia and many others. I cannot recall a single debate or Starred Question where the issue of how services would be either safeguarded or delivered under the proposed reforms of the NHS was not raised in one way or another. The Conservative-led Government have been telling us this comforting notion that your family doctor will commission the services that you need-and who better to do so? I am on the record as saying that I support that in principle. However, Conservative MP Sarah Wollaston rather let the cat out of the bag when she wrote in the Guardian on 4 January:

"I know many GPs who are keen to tackle the redesign of care and even the issue of failing colleagues, but I know none that are interested in EU competition law. If commissioners cannot design care pathways free from the spectre of lawsuits from private providers, they will hand over to commercial commissioners prepared to take the rap".

I think that that means that private commissioners may turn to private providers at the expense of NHS providers because of the intimidation, or their interpretation, of EU competition law. Will the Minister confirm the role that EU competition law will play in the forthcoming reforms? For example, will GP commissioners be able to choose NHS providers where they offer the best quality and comprehensive service even if they are not the cheapest, without fear of legal challenge from private enterprise cherry-picking the most lucrative contracts? The Minister will know that I have long been a supporter of choice and diversity within the NHS, but the question of how we achieve that might lead to a fundamental dividing line opening up between us.

The EU competition rules being used as a regulator for NHS services through Monitor provides us with a huge problem. The problem, if I might put it in shorthand, is that health-providing companies owned by shareholders and hedge funds are not independent providers; they are accountable to owners who want to see a profit. So patients and organisations that promote the interests of long-term conditions, for example, are correct to be asking how health services owned and run by these people will have their long-term interests at heart. These are the questions that we will need to answer when we look at the NHS Bill that is promised next week.

What role does the Minister envisage for the market, for competition and for the private sector as a result of these proposed reforms? Does he believe that collaboration or competition is the best way to run our health service? I promise noble Lords that the noble Baroness, Lady Finlay, and I have not collaborated in asking that question. These are very big issues to which, as I have said, I suspect we need to return for longer and deeper consideration.

I conclude by raising a specific issue-in many ways, a perfect example of the anxieties that are being raised in all quarters. This concerns GP commissioning and the future of cancer expertise in the new system, and I thank both Cancer Research UK and Macmillan Cancer Support for drawing this to my attention. Before I go on, I add my congratulations to the noble Lords, Lord Crisp and Lord Kakkar, who asked questions that drilled down into the detail that we are going to have to address, as indeed did my noble friend Lord Winston.

As the Minister will know, the cancer networks have been an absolutely integral and important tool in improving outcomes for cancer patients. The Government have said in the new cancer strategy, Improving Outcomes: A Strategy for Cancer, published yesterday, that cancer networks will continue to be funded during the transition period to GP commissioning. How will GP consortia make use of the expertise currently available in cancer networks to help in the effective commissioning of high-quality and seamless cancer services? How will the Government ensure that the functions currently provided by networks are not lost and standards compromised under the new commissioning regime? Will the Government ensure that cancer networks are funded throughout the transition period until 2014? Will that funding include funding that cancer networks receive from PCTs at the moment as well as directly from the Department of Health? How will GP consortia be incentivised to ensure that the critical functions of cancer networks are still carried out as they commission cancer services?

I am happy if the Minister wants to write to me about those questions; it is unfair to expect him to answer them in detail at this moment. But they are very important, and I look forward to his remarks.

Photo of Earl Howe Earl Howe The Parliamentary Under-Secretary of State for Health 5:50 pm, 13th January 2011

My Lords, this has been a wide-ranging and well informed debate. I thank the noble Lord, Lord Turnberg, for calling it and all noble Lords who have spoken so eloquently. It is particularly right that I should single out for special praise my noble friend Lady Jolly, who I am delighted to welcome to your Lordships' House and our health debates.

The wording of the question that we are debating hints at some nervousness about the Government's reform proposals. I understand and appreciate many of the concerns that have been articulated today. There is, however, one simple truth about the reforms: they are necessary to create a sustainable NHS for the future. To make efficiency savings you have to improve commissioning and address the long-standing problems in a minority of challenged providers. It is for the long-term as well as the short-term future of the health service that we are working, and I remain exceedingly optimistic about that future.

The Government are fully committed to the NHS and its values and principles. We have prioritised its budget. Total health funding will rise by more than 10 per cent over the spending period. We are also starting to cut spend on administration to focus funding on the front line. The right reverend Prelate voiced some perfectly legitimate concerns about implementing change at a time of financial challenge. I agree with him that the future will see a great deal of change for the NHS. We are not shying away from the difficulties this will present, even within a protected budget. Increasing demands on the NHS mean that we will need to make the budget stretch further than ever before. However, I do not agree that a tighter budget necessarily leads to worse care.

Our reform agenda is entirely focused on improving the quality of healthcare services. Our vision is to improve health outcomes so that they are among the best in the world, and to bring about a genuine shift in power away from the state and towards the front-line staff and the people who use services. The reforms are designed to lead to better quality and more consistent commissioning so that outcomes for patients improve; drive up the quality of care through patient empowerment and choice; give providers greater freedom to innovate; and create a level playing field with fair pricing, encouraging services to be more responsive to patients' needs.

There is a clear focus on quality throughout our reforms. To name but a few, there will be payment incentives for quality through the Quality and Outcomes Framework, CQUIN and the tariff. Under the health and social care Bill, which will be introduced shortly, the Secretary of State, the NHS commissioning board and GP consortia will also be required to act with a view to securing continuous quality improvement in services provided by the NHS.

To achieve optimum outcomes for patients, we are transforming how quality is measured and how the NHS is held to account, shifting the focus away from centrally driven process targets towards improved outcomes, with the NHS held to account against a new NHS outcomes framework. Patient choice is not an end in itself but the focus on choice will drive up the quality of services and therefore improve outcomes. There will be greater access to information and-not least for chronic disease, which was mentioned by the noble Lord, Lord Kakkar-patients should have a greater feeling of empowerment.

The noble Baroness, Lady Masham, focused on specialised services, particularly for spinal injury. I will write to her on the detail of her questions. We recognised the needs of patients for specialised services when we drew up the reform programme last summer. Patients accessing specialised services should receive high-quality, effective, evidence-based treatment and care with improved outcomes. Our proposal is that the NHS commissioning board should commission specialised services. Responses to the public consultation have generally supported this proposal. However, the system will allow for flexibility in who commissions which services, allowing for changes over time as needed.

The noble Lord, Lord Kakkar, asked me about definitions. There will be the flexibility to change the definition of specialised services so that more or fewer services are commissioned by the board. This will allow the system to align with changing patterns of care. Additionally, there will be flexibility for consortia to decide how to commission other low-volume services; for example, by federating together.

The key point here is that we recognise that there is no one size fits all organisational structure that will work for all services equally. Therefore, we are moving away from specifying a fixed number of local or regional commissioning bodies to create a much more flexible structure where consortia can grow or shrink and can work together and with the NHS commissioning board in order to commission high-quality care most effectively. I say to the right reverend Prelate in particular that we will maintain our focus on the quality of care throughout the transition to the new system. Transition will occur through a carefully designed and managed process allowing for rapid adoption, system-wide learning and effective risk-management. We are determined fully to support the NHS during these changes.

The noble Lord, Lord Turnberg, asked me some specific questions about whether there were to be any cuts in the number of trainee doctors. The number of trainee doctors should be appropriate to meet the estimates of future demand for trained doctors. This year the entry to postgraduate medical training will be around 6,800 in total. That is in line with the recommendations from the Centre for Workforce Intelligence report on 2011 training numbers that analysed trainee doctor intakes in the context of long-term demand for consultants. The Centre for Workforce Intelligence will continue to provide that kind of analysis to us. The noble Lord asked about GP pathfinders. We are engaging with the first group of pathfinders to consider some of the very questions that he posed. We will be hosting a learning event for pathfinders later this month to explore those issues and to showcase the early impact of emerging consortia. It will be the responsibility of the NHS commissioning board to produce and publish an analysis of the findings of the pathfinder programme and set out the lessons learnt but we are also setting up a learning network to ensure that the experience of pathfinders can be quickly shared through the wider GP community. The learning from the pathfinders will touch on both the areas that the noble Lord raised. One will be to look at some of the structural principles such as the successes and obstacles that consortia of different sizes come up against. But we want pathfinders to start making a difference for their patients now, and so improving services for patients is the area into which pathfinders will be putting most of their efforts.

The noble Lord also raised the issue of integrating care and the spread of good practice and how that will be incorporated into contracts. One of the key roles of the board will be to provide national leadership for driving up the quality of care. I say that also to the noble Baroness, Lady Sharp, who asked me about this. It will help spread best practice by publishing commissioning guidance and model care pathways based on the evidence-based quality standards that it has asked NICE to develop. It will develop model contracts and standard contractual terms for providers. It will also develop the commissioning outcomes framework. I could go on about more areas of support that consortia will get from the board but I hope this reassures the noble Lord that our reforms will mean that good practice is embedded far more widely and more quickly than it is in the current system.

The noble Lord asked how the expertise and knowledge of clinicians in secondary care would be built into this process. That was an issue raised also by the noble Baroness, Lady Sharp, and, in a different way, by the noble Lord, Lord Touhig, in relation to dementia care. It was also alluded to by the noble Lord, Lord Kakkar. We have consistently emphasised the importance of multi-professional involvement in commissioning and we expect that this will be one of the areas that will be examined as part of the pathfinder programme. Good commissioning and the designing of care pathways will naturally involve a wide range of professionals and we would expect GP consortia to engage other health and care professionals in their commissioning work. Incidentally, I say to the noble Lord, Lord Kakkar, that we will continue to support the previous Government's programme of integrated care pilots.

The noble Baroness, Lady Sharp, asked me how health and local government services will be joined up. For the first time local authorities will have a lead role in improving the strategic co-ordination of commissioning across the NHS, social care and related children's and public health services. The new health and well-being boards will bring together the key leaders across these services to work in partnership and to develop a joint health and well-being strategy for their area. I hope that that partly reassures her that the services she particularly mentioned will certainly not be lost sight of in that process, because there is a fundamental synergy in the structures that I have referred to.

The noble Lord, Lord Turnberg, asked what is to happen to OSCHR, the Office for Strategic Co-ordination of Health Research. It has done a fine job over the past three years. It is a very useful mechanism for facilitating processes for joint working, focusing particularly on translational research. That body will continue with an increased focus on co-ordination and foresight.

The noble Lord also asked how GP consortia will be incentivised to be involved in health research. I recognise his concerns. There is not time for me to say a lot, but the department is funding the National Institute for Health Research Primary Care Research Network. This brings together a wide range of primary care health professionals and is dedicated to expanding clinical research in primary care. The Academy of Medical Science's report, which the noble Lord referred to, was published this week. We welcome the report and we are carefully considering how to implement its recommendations. I will write to him further on that.

The noble Lord, Lord Winston, asked in particular about how academic medicine will be protected. The Government recognise the crucial importance of academic medicine; we are increasing funding for health research, as has been mentioned, part of which supports lectureships and other awards, and we are currently consulting on our proposals for education and training. However, again, perhaps I may write to the noble Lord with further and better particulars.

My noble friend Lord Colwyn spoke on his specialist subject of dentistry, and perhaps I can make some amends for my previous omissions on this score. The Government are committed to piloting the new contracts before introducing any of them at scale, to ensure that lessons are learnt and acted on. The design and introduction of a new contract will be a key part of the piloting process. The BDA has welcomed that. Representatives from the profession have been closely involved in the work to develop our proposals. The intention is for the National Health Service commissioning board to commission secondary care to ensure consistency of approach. Again, time prevents me answering some of his further questions.

On herbal medicine and the possible regulation of authorised practitioners, I cannot go much further than I did in my earlier Answer to the noble Lord, Lord Pearson, other than to acknowledge my noble friend's rightful concerns and to re-emphasise that we are taking our deliberations forward as a matter of urgency.

The noble Baroness, Lady Sharp, asked who will oversee hospital expenditure. The answer is that that will be done by governors in foundation trusts, who will scrutinise trust board expenditure. She also asked me about NICE, as did the noble Baroness, Lady Meacher. NICE is recognised as an international leader in the evaluation of drugs and health technologies and will continue to have an important advisory role, including assessing the incremental therapeutic benefits of new medicines. However, as we implement our plans for value-based pricing from 2014-a little way ahead-NICE's role will inevitably evolve. Its work will increasingly focus on giving authoritative advice to clinicians on how to deliver the most effective treatments and on the development of quality standards.

I am conscious that I have overshot my time. Although there is technically time in hand, it would not be courteous to the House if I continued. I have many further answers and I apologise to noble Lords whose questions I have not reached. I will write to them as fully as I can. I apologise in particular to the noble Baroness, Lady Finlay, whose questions I was very keen to answer.

I recognise that these reforms will be undertaken in a challenging context in which staff and leaders across the NHS face personal and professional uncertainty about their futures. However, the enthusiasm shown by commissioners, providers, managers and clinicians to bring the new system into being makes me certain that success is achievable.