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What a difference between a small developing country and the United Kingdom. Of course, that got me thinking of this wonderful service, the National Health Service. I know that all noble Lords during this debate have told different stories, but let us pause for a moment and consider what the Government are offering the people of Britain and how lucky we are to benefit from healthcare at the point of need.

On 21 February, the Minister, Ivan Lewis, announced a £20 million cash boost to improve palliative care services for children with life-limiting and life-threatening conditions. The funding boost will enable some of the country's very ill children to be cared for. If they are incurable, they will have the choice of saying whether they wish to die in a hospice or at home. There is currently a grant of £27 million over the next three years for children’s hospices and home care. This announcement extends the Government’s support for a further two years, with funding of £10 million a year until 2011.

On 18 February, the department’s target of reducing by 40 per cent deaths from cardiovascular disease for people under 75 has been met five years early. The coronary heart disease national service framework progress report published on 18 February states that the early delivery of the target has been made possible because waiting times for heart surgery have dropped dramatically since the introduction of the framework in 2000. No patients wait more than three months for heart surgery, compared with more than 5,500 patients in previous years. Prescriptions for cholesterol-reducing statins have more than doubled in the past three years, cutting both mortality from coronary heart disease and the yearly number of heart attacks. Emergency care is delivering thrombolysis more quickly for people suffering a heart attack. In early 2001, 24 per cent of patients received thrombolysis within 60 minutes of a call for help. Now it is almost 70 per cent.

We now know that National Health Service funding rose from £69 billion to £92 billion in the financial year 2007-08. Since 1997, when the present Government took over, staff numbers have grown by more than 224,000 appointments, including 1,300 GPs. Job satisfaction levels are at 73 per cent. We now have some truly remarkable figures to back up the claims that healthcare at the point of need is not a slogan, but a fact. It is true that we still have a long way to go—other noble Lords have given us many examples—and that we still have a critical public, but I ask noble Lords to compare this with countries in which sick people have to pay for their care, however large or small the bill. I am sure they will understand that the people in the hospitals or the caring professions are not robots but people who are working at their best. If government funding is well delivered, they will be able to improve the service. I suggest to the Government that it might be useful for anyone who has had medical care to receive a bill that says, “Paid for by your National Health Service”. The people of this country would be able to appreciate the wonderful gift of healthcare at the point of need.



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3.33 pm

Lord Mancroft: My Lords, I too am grateful to my noble friend Lady Eccles of Moulton for giving us this opportunity to debate this subject. It is the first time that I have ever spoken in a debate of this sort, because the amount that I know about running hospitals and healthcare could be put into a nutshell, leaving ample room for the nut. I have always been lucky to enjoy very good health until last year. I was taken ill shortly after the Recess started, and in the latter half of last year and at the beginning of this year I became an expert in being cared for in a variety of different hospitals, so I shall now give the House my observations as the person at the other end.

When I was taken ill, I was taken to an accident and emergency department in a hospital not in London but in the West Country. I can tell your Lordships only that it is a miracle that I am still alive. It was exactly as the noble Baroness described the hospital down in Maidstone in Kent. I will not tell your Lordships which hospital I was in, but the wards were filthy. Underneath the bed next to me was a piece of dirty cotton wool, and there it remained for seven days; the ward was never cleaned. It was a gastroenterology ward, with lots of people with very unpleasant infectious diseases. The ward, the tables, the beds and the bathrooms were not cleaned. I was extremely infectious at that time and no precautions were taken with me at all. The staff were furious when my wife wanted my bed cleaned when it clearly needed cleaning. I was just lying there, a pathetic person. It was appalling.

The nurses, who probably are the most important people in this complex area, were what I would describe as an accurate reflection of many young women in Britain today. What do I mean by that? I shall now break your Lordships’ rules and read the next bit, because I thought very hard before I wrote it. The nurses who looked after me—not all of them; we should never generalise and there were one or two wonderful ones—were mostly grubby, with dirty fingernails and hair. They were slipshod, lazy and, worst of all, drunken and promiscuous. How do I know that? If you are a patient, lying in a bed and being nursed from either side, the nurses talk across you as if you are not there. I know exactly what they got up to the night before. I know how much they drank and what they were planning to do the next night, and it was pretty horrifying.

My bed was next door to the nurses’ station, so you could see how the whole place was being run. Actually, you could not: I have seen lots of things being run, but after a week, I could not tell you who was in charge. I had absolutely no idea who was telling who to do what. My view is that nobody was telling anybody.

The man opposite me was dying. I imagine he died two or three days after I left. I do not know what he was dying of because he was not doing a lot of talking. But I do know that he virtually died alone. The nurses thought that he was a nuisance. They changed his bottle, gave him his pills, occasionally fed him and propped him up. But basically this man died alone in a British hospital in the 21st century, and I had to watch him do it, which was pretty unpleasant.

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I was saved from that and I have a happy ending to this story. My wife very kindly kidnapped me and put me in an ambulance, on the advice of my London consultant. I was brought up to London to the Chelsea and Westminster Hospital, which is where the story changes. I went to the Thomas Macaulay ward, which was completely incredible. The nurses, of every nationality, size, shape and colour, were wonderful. I was discharged from the country hospital. When I arrived in London I had two operations in 24 hours. I am quite certain—as were all the staff, although they would not say it—that if I had not had them I would have died. The hospital in London was wonderful. The nurses were marvellous. I do not know how, but it worked like clockwork. It was spotlessly clean. It was everything that it should be or could be anywhere.

But some things apply to both places. I have queued in many departments and met many consultants over the past six months. It is perfectly clear that there is far too much paper. Everywhere is swamped with paper. Everyone asks the same questions and fills in forms. Every department is covered in completely pointless paper. Last week, I saw one of my consultants. As I was leaving, he said, “By the way, what do you weigh”? I said, “What on earth do you mean, what do I weigh? Why do you want to know”? He said, “I do not want to know, but I’ve got to tick the box on this form or they will make you come for another appointment and weigh you. I run an outside clinic twice a week and 60 of my patients twice a week are weighed. I don’t care what they weigh. They don’t care what they weigh. But the form says that we have to weigh them”. How ridiculous is that?

Dispensing drugs is really simple. You and I call it retailing. Every week when I get my drugs, I watch them doing it and it takes 40 minutes. Over the road, Waitrose, the supermarket, is doing exactly the same thing really well, so why cannot these people do it? It is a shambles. It takes 40 minutes to get a drug which you can see sitting on the shelf. Why is that? It is because they have never been trained.

My last point is about the clerical staff, who probably are the linchpin that holds together these tiny satellites—the departments and areas of a big service in a large hospital. These people make the appointments and make sure that everyone is in the right place at the right time. They are clearly, too, completely untrained. I talked about it with one of my consultants who said that one of the problems is that the junior clerical staff in the National Health Service are desperately keen to help, very well meaning, completely useless and totally untrained. In the past year, I have observed them in 30 or 40 departments and I have come to the conclusion that that is true. The clerical staff are absolutely useless, but very nice.

Of course, this is a difficult situation. There will always be good and bad. In Britain at the moment there is very little that is good enough and too much that is too bad. This Government came in 10 years ago to sort this situation out. It has not been sorted out. It is internationally embarrassing and humiliating that a country of this size and wealth should produce a service which is so horrible.



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3.39 pm

Baroness Greengross: My Lords, in spite of the fact that older people are the main adult users of NHS services, Age Concern recently pointed out that the policy of care for older people is still not mainstreamed either in policy or practice, and last year the Joint Committee on Human Rights said that a total change in culture is needed if the human rights and dignity of older people are to be protected. I declare an interest as a vice-president of Age Concern.

An obvious example is dementia care. We know that the numbers affected are very large and growing, and yet dementia is only just beginning to feature in the Government’s strategy. Recently I took part in a small inquiry conducted by the All-Party Parliamentary Group on Dementia, of which I am an officer. Its results will demonstrate clearly that the poor and over-use of neuroleptic drugs to treat those suffering with dementia needs immediate attention.

Some 60 per cent of older people in general hospitals suffer from mental health problems, and there is a terrible lack of training among doctors and nurses not just in dementia, but also in depression and acute confusion, which is often not diagnosed. Moreover, many specialists do not get involved in the care of people with these conditions. Pre-registration training in the physical and mental health needs of older people is essential.

We know that the majority of older people are admitted to hospital as emergency patients. Many are vulnerable and nearing the end of life, and the basic standards of care that they need are not always reached. These include privacy when using the toilet, still being admitted to mixed-sex wards and the involvement of their carers not being allowed. We also know that safe and well planned discharge is still only a dream for many. Discharge should be planned either before or on arrival in hospital, and should not be directly to a care home. An example of this was the discharge of a 94 year-old I know well from one of our main teaching hospitals in London. He came in as an emergency in bare feet with pyjamas and a dressing gown and was discharged in bare feet with pyjamas and a dressing gown on the wrong side of the road from his flat. He had to cross that road and get up the stairs. This happened not long ago. Another gentleman nearing 80 was admitted as an emergency to another of our London teaching hospitals and asked for an extra pillow to relieve the pain in his back. It was impossible to find him one all night. Sadly, such problems still arise.

The noble Baroness, Lady Knight, is a champion of better nutrition. We know about malnutrition in hospitals, and many older people are malnourished on admittance, although equally many are not. The noble Baroness, Lady Masham, also made the point that in cases of malnourishment, help with eating is essential. There was a time when nurses did this as part of their routine, and we need to go back to that sort of care. It is essential for those who are frail and vulnerable and who have to go into hospital.

Many people who are terminally ill or nearing the end of their life want to die at home, or if necessary in a hospice, because of the privacy offered and the right

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to die with their loved ones present, and the loving and tender care they want to be sure they will receive at that point in their lives. Dame Cicely Saunders, who brought the idea of hospice care to the world, would be upset if she knew that so many people who want such an end to their lives are not able to receive it, and die in hospital wards. Again, a great friend aged 102 died a couple of weeks ago in an open ward rather than in a hospice. Around 70 per cent of people still die in that way. This is quite unacceptable. Enormous progress has been made in the development of healthcare, and I acknowledge that and rejoice in it, but there is still a long way to go.

The document, Standards for Better Health, is excellent, but many patients and most of the general public do not know that it exists. Patients need information, so the Department of Health should make information about the standards which patients have a right to expect available for any organisation providing NHS services, whether they are provided in hospital or in the community. We must do that and make sure that people are given the dignified, loving and tender care they need when they are old and frail, and nearing the end of their lives.

3.45 pm

Baroness Barker: My Lords, I, too, congratulate the noble Baroness, Lady Eccles of Moulton, on the eloquent and elegant way in which she introduced the subject, which has turned out to be fascinating. When I was preparing my speech last night I predicted that noble Lords would come at this from a variety of angles, and so it has proved. It is a timely debate, coming as it does at the end of this three-year period of unprecedented financial investment in the NHS and just before the publication of the much heralded review of the noble Lord, Lord Darzi.

The key question running through the debate is how does one determine quality in a service that sets out to meet the needs of 55 million people. Of the speeches today, I would pick out those of the noble Lords, Lord Parekh and Lord Mancroft, and the noble Baronesses, Lady Murphy and Lady Howells of St Davids, as examples of the different ways in which people are tempted to answer that intriguing question.

The problem in the NHS is not lack of quality measures. On the contrary, over the past few years it could be said that the NHS has had an epidemic of quality measures at every level in efforts to demonstrate the justification for finance and the effectiveness of what it does. Core standards, waiting times, four-hour waiting time in A&E, quality and outcomes frameworks for GPs, quality-adjusted life year measures for clinical interventions, NICE evaluations, star ratings and so on. I am beginning to sound like Clement Freud on “Just a Minute”; I could go on and on.

The NHS is a data rich organisation but, as the noble Lord, Lord Mancroft, showed in a graphic way, if your Lordships could do only one thing to help the NHS to be the best organisation in the world that it could be, you would kill the disease of duplication within the NHS. For those who have the miserable job of trying to track information flows throughout the NHS, it must be akin to the children’s game of hunt

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the slipper; the amount of duplication of information is immense. Who collects the data, where they are held and what happens to them is something of a mystery. Until we can find answers to that it will be impossible ever to truly demonstrate the overall effectiveness of the NHS.

I do not wish to suggest that the development of quality measurements is unimportant—it is not. It is indisputable that in some areas the existence of targets and the development of metrics have led to improvements in care. In cancer treatment, for example, the combination of a national strategy, the involvement of clinicians and charities in the development of research and increased funding has led to new developments such as the introduction of specialist nurses. This has led to better treatment and outcomes for patients. But, at the same time, in one of the flagship services, while there have been improvements with the big four cancers there are still vast areas of cancer treatment where this country lags way behind countries in which there is nowhere near the level of investment that we have.

As a result of listening to clinicians, managers, researchers and patients, my Liberal Democrat colleagues in another place have drawn up our party’s new health policy. We will debate that policy in two weeks’ time. As a democratic party, members still have the ability to decide policy, so I cannot actually say that it is our policy as yet, but I hope that it will be. A key part of that is the understanding that in order to be the best quality health service in the world, patients have to be empowered to improve the quality of care in conjunction with clinicians.

Therefore we have four key proposals within that policy. The first is a pilot of patient advocates dedicated to providing information, guidance and support to patients and carers in navigating the most complex health and social care system in the world. We would replace national targets with a system of universal entitlements, enshrined in the patient contract, which would outline minimum standards of access to primary, secondary and tertiary care services. We would expand the use of individual budgets to specific areas within the NHS, such as core services like treatment for chronic conditions. We would pilot patient-reported outcomes measures that would measure patient experiences while recording the actual benefits, physical and mental, to patients’ health.

There is one key measure by which our proposal will, and should, be judged: the effectiveness with which it enables researchers, policymakers, clinicians and patients to acquire the evidence base that they need for different methods of treatment and care. The real problem we are attempting to solve is the complete disconnect between research proposals, evidence of treatment and cost effectiveness on the one hand and the levels of decision-making within the NHS on the other. That is the key aspect that the system lacks.

The Department of Health has been attempting to make improvements. It has developed the Better Metrics programme, which aims to provide more clinically relevant measures of performance. Will that programme be expanded to other areas of treatment? Through Connecting for Health, which was mentioned by the noble Baroness, Lady Eccles, that programme

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could be shared with patient groups so that we could continue to develop a policy of putting together patient experience alongside clinical evidence and evaluating the two together.

In the time available to me I wish to mention an area of health services that Members of this House have a duty to address regularly; that is, the provision of services to those people who receive the worst healthcare of all—prisoners. The Sainsbury Centre for Mental Health reported in 2007 that while most English prisons now have in-reach teams and, despite having staffing levels that are less that one-third of the equivalent community mental health teams, they are starting to make a difference to those prisoners who have severe mental health problems. However, the vast majority of patients do not have severe mental health problems; they have lower-level problems such as depression or anxiety. The best that some of them can hope for is to hold out for some Prozac—whether or not it is deemed to be effective.

Last week I spent some time learning about the work of an organisation called RAPt, the Rehabilitation of Addicted Prisoners Trust. It provides a particular form of therapy and support for addicted prisoners, both in prison and in the community. Whereas the majority of services for people with addictions under the Government’s existing addiction strategy, and under the updated strategy as announced by Jacqui Smith yesterday, are dependent on replacement therapies such as methadone therapies for heroin users, the programmes run by RAPt are abstinence programmes. They are intensive and consist of one-to-one help and support for people, based on a policy of abstinence. The organisation’s peer-reviewed results show remarkable achievements; of the people who complete its courses, 30 per cent manage to be completely drug-free. Another 30 per cent are drug-free for a while but may relapse because they return to the difficult situations from which they came.

The programmes are more expensive than replacement treatment such as methadone, but they are highly effective for some people. Will the Department of Health, in seeking to achieve good quality services for some of the most difficult NHS patients, commission a programme of research comparing abstinence programmes with methadone replacement therapies?

We have the most comprehensive health service in the world; we have the potential to have the most comprehensive research base in the world; we have the ability to take different forms of treatment and evaluate their efficacy across different control populations. We also have staff who continue to hold an outstanding public service ethos. They deserve to know whether what they do is effective or, as the noble Lord, Lord Mancroft, graphically showed, could be improved. For their sake and that of all patients, the noble Baroness, Lady Eccles, was right to focus the attention of this House on the key question of what quality is and how we measure it.

3.55 pm

Earl Howe: My Lords, it is gratifying and perhaps not altogether surprising that my noble friend’s Motion should have given rise to such a wide-ranging

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set of speeches from all sides of the House, and I congratulate her as much on facilitating that as on her own powerful contribution.


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