It is a great pleasure to follow the right hon. Member for Rother Valley (Kevin Barron) who has chaired the Select Committee on Health and who made some extremely important points about accountability. This has been an interesting debate, much of which has focused—understandably, given its title—on what is happening in Staffordshire a year on from the Francis report into Mid Staffs hospital. It is also understandable that considerable cross-party
concerns have been raised about the NHS in Wales. The Francis report applied to the whole of England, and I want to make some observations as a non-Staffordshire Member of Parliament who has benefited from it.
Much has happened during the last year—for example, the appointment of Stuart Rose, former head of Marks & Spencer, to advise the Government on leadership. His brief is to explore how the 14 NHS trusts placed in special measures can be helped to tackle concerns about their performance. David Dalton, chief executive of the Salford Royal NHS Foundation Trust, is exploring how NHS providers can collaborate in networks or chains, effectively building on an initiative last autumn in which high-performing NHS hospitals were invited by the Secretary of State to provide support for hospitals placed in special measures.
I suspect that much remains to be done to tackle relational aspects of care, including ensuring that patients are treated with dignity and respect and are able to communicate effectively with doctors and other staff. Indeed, the NHS as a whole, including GPs, will probably need to do a lot more in future to support patients to manage their own health and well-being and involve them as partners in care. Sir David Nicholson, the head of NHS England, who retires shortly, has described this concept as “the empowered patient”—in essence, the need for us all to get better at managing our own health problems to reduce the burden on hospitals.
Everyone has had to learn lessons as a consequence of the Francis inquiry, but it is not appropriate or, indeed, fair, continually to castigate those working in the NHS, whether they be nursing staff or managers. On the contrary, we need to ensure that NHS staff are supported to do the job for which they have been trained. Not unreasonably, as in other aspects of life, there will be a close correlation between staff experience and patient experience. Patients receive better care when it is given by staff working in teams that are well led and where staff consider that they have the time and resources to care to the best of their abilities. One reason ward sisters have always been so highly valued is that they are an extremely good example of team leaders, as experienced nurses who have developed, and are able to pass on, a culture in which patients are treated with dignity and respect, and who motivate their colleagues to do the same.
If we are to have an NHS fit for the 21st century, we need continually to attract talent into it. We will not do that if people consider that those working in the NHS are all too often set up to fail. We also need to improve efforts to attract clinicians into leadership roles, as advocated by Roy Griffiths way back in 1983. As a senior and much-respected clinician and physician, Sir Jonathan Michael has been able to achieve as chief executive of Oxford University Hospitals NHS Trust much that I suspect could not have been achieved by a chief executive who was not a clinician. We should value the role of managers in the NHS instead of constantly criticising them. Successful leadership in the NHS needs to be collective and distributed rather than residing in just a few people at the top of NHS organisations. The involvement of doctors, nurses and other clinicians in leadership roles is essential.
The NHS is an organisation that is constantly evolving. The NHS of today is very different from the NHS of 30 years ago, when my father retired as a consultant physician, and the NHS of 30 years ago was very different from the NHS on the day that it began. Both my parents worked in the hospital service on day one of the NHS, my father as a young registrar and my mother as a theatre sister. There is a danger that our perceptions of the NHS, and of what hospitals should look like, become frozen in time, with James Robertson Justice as a snapshot of hospital care. The type and nature of illnesses that hospitals are having to treat changes over the years; so too, therefore, does the hospital layout. I recollect that my father had four Nightingale wards, two male, two female, with 15 beds along each wall and 30 beds to a ward, filled almost entirely with patients dying from lung cancer. Lung cancer is still a killer, but not in anything like the numbers then. We need to recognise that hospitals are changing. In that regard, I very much welcome the work of the Royal College of Physicians through its future hospital commission—an initiative that has not received anything like the publicity and debate that it merits.
The current pattern of acute care is based on the model of district general hospitals providing comprehensive emergency and elective services for relatively small populations—a model developed back in the 1970s. A whole number of factors are changing that model. For example, advances in medical technology mean that it is now possible to treat many patients much more speedily and less invasively. Hysterectomies that might previously have involved a woman patient remaining in hospital for up to 10 days can now be performed through keyhole surgery involving a much shorter stay. There is clear evidence from the Royal College of Surgeons that specialisation can achieve better outcomes. Indeed, the concept of the general surgeon, or surgeon specialising in general medicine, is now pretty much obsolete. Almost all surgeons practising in the NHS today specialise, to the benefit of their patients, in surgery on a particular part of the anatomy.
On the other side of the equation, there are significant demographic changes, resulting in increasing numbers of elderly people. The elderly population is set to expand exponentially as we post-war babies, with much longer average life expectancies than our grandparents, start to reach our 70s and 80s. Many more frail elderly people have long-term medical conditions and an increasing number of people have multiple long-term conditions and—that terrible word—comorbidities.
I therefore very much support the 11 core principles of the Royal College of Physicians’ “Future hospital” report. We need to ensure that NHS patients are at the centre of care—what Robert Francis described as a “patient-centred culture”. We need to ensure that the NHS provides a seven-day-a-week service and that hospital trusts have a 24/7 approach. It is clearly unacceptable that mortality rates are significantly higher for patients admitted into hospitals at the weekend. GP out-of-hours services need to be improved and co-located, and hospital emergency departments need to integrate the urgent care pathway.
At the Horton general hospital in my constituency, an emergency medical unit is being developed to help strengthen the A and E unit and its rapid medical assessment capabilities and to try to ensure that people
go to A and E only if they really need to. The links between generalist and specialist pathways are being strengthened, but I suspect that the 24/7 approach will lead to some reconfiguration of services, although that should not necessarily mean that they will become more remote. For example, Horton hospital now has a daily fracture clinic throughout the week and a renal dialysis unit, because it makes more sense for those services to be delivered there. However, emergency abdominal surgery is now carried out at the John Radcliffe hospital in Oxford.
In all of this, we need to remember that whoever is in government, and whichever political party or combination of parties is running the country, we need to collectively face the Nicholson challenge of saving significant amounts of money in the running of the NHS. If we cannot manage the Nicholson challenge, the NHS simply will face a black hole in funding and will fall, more or less, into managed decline.
Indeed, in a recent press report, Sir David Nicholson is reported as predicting that, if the NHS does not pursue a number of reforms, including enhanced primary care, more GPs and more specialisms, it faces
“a £30 billion hole in funding by 2021”,
which is certainly within the political life expectancy of many of us in this House. He also observed, rightly, that
“the NHS is not frozen in aspic for us to worship as some great thing—it will decline and it will die if we don’t recognise the choices that are available to us now”.
Over the past year, following the publication of the Francis report, there has been considerable progress, including towards greater openness and transparency in the health service, including the implementation of a new statutory duty of candour. England now leads the world in transparency and openness about surgeons’ clinical outcomes, so patients can access their surgeons’ outcomes for particular procedures or operations, such as hip replacement. There has been considerable improvement in the Care Quality Commission’s inspection model, the Government have ensured that a named consultant is in charge of someone’s care throughout a hospital stay, and there is clear recognition that the NHS needs to provide a seven-day-a-week service.
We need to move forward with a health service that puts patients at the centre of care. A number of years ago, nursing was made increasingly a graduate profession, but whether one is a graduate doctor or a graduate nurse, patients still need tender loving care. I do not think that my mother, when she was a ward sister, was ever too proud—or considered it not to be part of her role, if necessary—to ensure that patients were comfortable in bed, to give them a bed bath, to make sure that they were eating properly or, if they should die, to ensure that they were laid out with dignity and care.
There have been concerns about health care support workers and we should welcome the recent review by Camilla Cavendish, which has made a number of recommendations on the training of and support given to health care assistants and how that can be improved. Health care assistants do extremely valuable work in hospital. They should be valued and properly regulated.
Last Friday I attended an open day for care workers, which was organised by Oxfordshire county council because, given the ageing population, we are going to need many more health care workers in hospitals and nursing homes and to give domiciliary support.
We have yet to see the full benefits of commissioning and the extent to which commissioners can help improve and monitor the quality of NHS care. One thing that has interested me in this debate is the issue about who actually runs the NHS, because I assumed that once we had commissioning bodies, they would drive where the money was spent. We have also yet to see the full benefits of the new governance arrangements in the NHS, and of ensuring more joined-up working between the NHS and other providers, such as through health and wellbeing boards. Healthwatch Oxfordshire is certainly still getting into its stride as an organisation.
I hope that the House will have an opportunity, in a Back-Bench business or Westminster Hall debate, to discuss the Royal College of Physicians report on the future hospital programme. It is in the process of establishing development sites, which will implement and further develop the recommendations made in its report. I certainly hope that it will consider the Horton general hospital as one of those development sites, not only as one of the smaller general hospitals in the country, but as a hospital that serves a large geographical catchment area.
As Chris Ham, the chief executive of the King’s Fund has observed, high-performing health care organisations
“benefit from continuity of leadership, organisational stability, and consistency of purpose”.
I suspect that, having learned the lessons of Mid Staffordshire, we now need to concentrate on ensuring that there is continuity of leadership, organisational stability and consistency of purpose in the NHS.
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