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.