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Health: Primary and Community Care Debate 24th June 2010

Lord Mawson: My Lords, it is a privilege to be able to lead this debate on the future of primary and community care at this early stage in the new coalition Government. The vision that the Government have set out for primary care, where resources are deployed in the hands of practitioners close to the ground, has significant risks but is full of opportunity. As a social entrepreneur, I welcome this bold step.

As noble Lords will know, over the past 13 years in an area of great deprivation and health need, where the health authority had left a gaping hole in primary care provision, we, with the local community of Bromley by Bow, have set up a health centre which is integrated with housing, education, businesses and the arts. I declare an interest as the founder and, now, president of the centre, and that, in my professional life, I am increasingly working across the country advising on this area of health development.

The Bromley by Bow Centre is about health, not sickness, which is reflected throughout the building. You enter through a beautiful cloistered garden, recently full of purple wisteria. There are no gruesome pictures of human bodies on the walls greeting our patients, the kind of images that used to haunt me as an imaginative eight year-old at our local doctor’s surgery in Bradford. Instead, you walk into an art gallery and open-plan reception made of natural timbers and bathed in natural light. A high-quality environment, a focus on human relationships, open communication and customer focus are the keys to the Bromley by Bow approach. Doctors come out into the reception to chat and greet their patients in person. In the consulting rooms, patients and doctors sit side by side around curved wooden tables, looking at the computer screen together. At Bromley by Bow, doctors, nurses and patients work in partnership together.

Patients are not merely prescribed pills, referred and sent on their way. The drug we give to a patient with depression is only part of what our GPs prescribe as a fully comprehensive care programme. At the centre, we can offer on-site career advice; support to overcome debt; vocational training qualifications, and even a university degree programme; business support, including the opportunity to set up your own business; and practical housing and legal assistance.

Over the past 13 years the Bromley by Bow Centre has become an exemplar of an integrated approach to health and social care. It inspired the £300-million healthy living centre programme, run by the then New Opportunities Fund, and the £2-billion NHS LIFT initiative, which is of course the public/private partnership programme for building primary health and social care centres in the most disadvantaged areas across the UK.

Others have developed integrated approaches to health in other parts of the country. Dr Angela Lennox built a police station in her health centre in Leicester and reduced crime in the housing estate where it is based. The Westbank Community Care Centre in Exeter promotes healthy living across Devon. The Gracefield Gardens health centre in Streatham works in partnership with Lambeth PCT and Lambeth Council to deliver better healthcare. We ourselves now run three health centres for over 18,000 patients and are the largest primary care provider in the London Borough of Tower Hamlets.

I apologise for not being able to speak last week in the debate on the big society, but are these not all examples of where, in the micro, a big idea like the big society might take root? If integrated models of health and community care were encouraged in every community up and down the land, and the necessary local relationships and partnerships brought together, this important idea-the big society-might not become subject to yet further cynicism and be seen as more meaningless government spin with little substance underneath. It might actually become the fertile ground within which a wholly new definition of what it means to be a healthy society-a thriving community-took root. Of course, such an approach would need to be given time and consistent leadership.

There is a wealth of untapped social entrepreneurial talent in our country. Many of these entrepreneurs have it in them to generate creative and innovative approaches to primary and community care. There are hundreds of latent and undernourished third-sector organisations in this country with the capability to become like Bromley by Bow and take on the task of transforming how public services are delivered in communities up and down the UK. Our task is to find these people and organisations and put the wind in their sails. Over the past 10 years I have travelled up and down the country and discovered social entrepreneurs who are massively frustrated at how hard it is to be trusted and resourced to take on public contracts, including in the areas of health and social care. Despite the positive rhetoric from successive government Ministers, it has been intensely difficult for dedicated and talented social entrepreneurs to develop creative solutions.

My noble friend Lady Finlay and I offer the Minister a visit to some of these centres and the opportunity for him to see in detail what a successful integrated approach to health and community care actually looks like in practice, and what conditions need to prevail if it is to grow exponentially and to take root. The sad fact remains that these examples of an integrated health model are still few and far between. Despite all the rhetoric and promises, there has been little practical encouragement for these integrated approaches to health. It was ironic that our approach, which everyone now thinks is a great idea, was physically blocked by a boulder across our road to delivery back in the mid-1990s. The boulder was not local people but the local health authority at that time.

I am not convinced that things have moved on much. Yes, money has been spent on building new buildings and, yes, there has been investment in services, but the principle of broadening the base of primary and social care delivery and engaging social enterprises has barely been understood. I am aware that the language of social enterprise is spoken inside Whitehall, but I am profoundly doubtful as to whether it is understood. Indeed, the evidence is that it is not. Our public services need to be known for doing and achieving, not just endless talking, restructuring or writing yet another new stack of policy documents. In a modern enterprise economy, we are nowadays returning to the sensible practice of “learning by doing”. The idea that we learn much through the writing of endless documents that are out of date within weeks can seem rather outdated. There is nothing better than getting your hands dirty in the practicalities to really understand what is going on. When I spoke to the recently departed chair of NHS London, he told me that his mission was to build stand-alone “medical model” health centres without what he called “the distraction of social and community care”. Evidently, the complications inherent in the lives of disadvantaged Londoners were outside the brief of the chair of NHS London.

Similarly, the vision of the noble Lord, Lord Darzi, of a network of polyclinics, announced in your Lordships’ House, was in practice another missed opportunity. When you get into the practical detail with those of us who are practitioners, you see that it was not at all a vision of polyclinics, but of monoclinics-that is, health centres that are almost solely about the clinical model of healthcare. It is a sophisticated clinical model and, invariably, these clinics are full of state-of-the-art equipment and procedures. However, I am vexed to say that they pay scant lip service to the lessons many of us have learnt about integration and the bringing of different disciplines together in the way I have described-that the route into addressing the pressing and underlying health needs in some of our most challenging communities in this country lies in getting GPs to work with their non-health colleagues. It is as simple and as complicated as that.

We need our health service to be open to working in partnership with the third sector and social enterprises in integrated schemes which address the real, practical day-to-day issues that face patients. These include poor social housing, underachievement in education, credit card debt and fear of bailiffs, concern over street violence and anti-social behaviour, and the lack of opportunities to take control of their lives. We are not asking the NHS to solve all these problems. We are simply asking that the health profession be willing to work more collaboratively with others who have the tools to change our communities for the better, including by addressing their physical and mental health needs.

What those of us who have had real experience of running successful integrated health centres found was that the definition of a polyclinic changed on a six-monthly basis, and each new definition was communicated by NHS London with such clarity and certainty that real players and practitioners in the field were left totally paralysed. This meant that important health centres still remain not built, with enormous potential abortive costs. I know of one health centre that has had to go through so many NHS London-inspired redesigns that it has incurred over £1.5 million of design fees and still sits in NHS London’s in-tray. I truly wish I could say that this is the only example I am aware of in London but it is not. I am afraid that the last Government were rather fond of initiatives that never in practice happened, and of trusting the reports of young consultants at McKinsey rather than those who do the job.

I welcome a world envisioned by the coalition Government where resources are put in the hands of practitioners on the ground with a real understanding of their neighbourhoods and local needs. However, this vision is far from straightforward. Not all GPs will deliver the integrated model of healthcare that I described earlier. Many GPs who support an integrated approach tell me that their colleagues who do not support it fear loss of status and title, without realising that real status in communities is based on the strength of their relationships with patients. Often in deprived areas there is a stark lack of GPs with the capacity to rise to the challenges that they now face. This new approach has important implications for the ways in which doctors are now trained.

The Government need to ensure that GPs are encouraged not to resist change, nor protect an expensive biomedical model of health. We need to show our doctors that an integrated approach to healthcare will address the profound problems that people in disadvantaged areas face, with considerable savings to the public purse. At Bromley by Bow, we run our health centre like any successful customer-focused business. For example, 20 per cent of consultations are conducted on the phone, which saves not only the patient’s time but the GP’s as well. What we all have to realise is that the NHS has access to people across the country which any business would die for. Eighty per cent of consultations in the NHS take place in general practice, and 90 per cent of the population is seen in any one year. If we encourage entrepreneurship in the world of health, then the more capable practitioners will step into these gaps in the market and ensure successful delivery of care.

As the new Government begin to formulate their health policy, I have three questions for the coalition and the Minister, who I wish to thank for a very helpful discussion earlier this week on this subject. First, what is the Government’s vision for the future make-up of primary and community care? Will they simply leave it to the marketplace? Will they promote the standard medical model or the integrated approach of the type I have described? A clear approach is essential for the dedicated medical staff, who have had to suffer countless changes in direction over the last decade and now feel disillusioned, confused and frustrated. Secondly, once the Government have clarified what their future model of primary care and community care will be, how will they deliver and develop this approach effectively? This has simply not been happening. Finally, who in the coalition Government will lead with consistency and longevity, and pursue this course? Under the previous Government, we saw a succession of initiatives and restructuring led by “here today, gone tomorrow” Ministers, which has left the health service, frankly, in ill health. Who will be the leader? That is my key question.

The Government are rightly opening up a world of opportunity and I welcome that. However, the devil, as ever, will be in the detail and perhaps most importantly in consistent leadership not from civil servants but from practitioners-GPs and others who have done the job and understand the practical details on the ground. I encourage the Minister and his Government to lessen their reliance on academics and theorists, who have often never built anything, and to embrace the world of the practitioner and the social entrepreneur; to create a culture where we learn by doing, and not by talking and writing endless expensive documents and papers. We cannot afford this expensive, rather old fashioned way of doing things any more. Let us support-and learn from-people who do the job.

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Debate on the Voluntary and Charitable

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Andrew's contribution to Litter debate

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Andrew's contribution to the 'Business and Society' debate

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If the present Government want to distinguish themselves from previous Governments and distance themselves from broken political promises, I suggest our politicians focus on three words: delivery, delivery, delivery. My colleagues and I have found that trust is created and local people participate when you deliver in practice on what you say.
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I would remind the House that the City, whose wealth came through the docks in east London, started with coffee houses where people met each other and did deals. This world was about relationships and integrity-”my word is my bond”. You can create endless regulation and legislation but if people do not act with integrity and relate to each other it will not work.

Andrew’s contribution to ‘Faith Communities’ Debate

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Today I am going further and put on the public record that the Secretary of State for Health is committing that the requirements in the public services Bill will be fully applied in relation to commissioning of NHS services through the procurement guidance that the board will produce on this. These were issues that were raised very compellingly by the noble Lord, Lord Mawson, and I pay tribute to him for his powerful and consistent advocacy on this theme”.

Andrew’s contribution to Public Services (Social Value) Bill

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I believe that change comes from within. It is not about a top-down or a bottom-up approach; change happens from inside out. The change I describe will happen only if we take in hand the outdated machinery of government and bend it to our will. This is fundamentally a practical task for practitioners and the Government would do well to point to them and celebrate their work. This is a job for the Brunels of this generation-the engineers and entrepreneurs. It is not a task for the faint-hearted or those Guardian readers who, in my experience, are all too content to analyse the world to death and comment from the sidelines through newspaper articles and government reports. Gird your loins for this practical task; it is time that we celebrated practical people.

Andrew’s latest contribution to the Localism Bill

12 July 2011

Often local authorities are actually not in touch with the practical opportunities on the ground presented by land and buildings.

Andrew’s thoughts on the Localism Bill

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My question to the Minister is: does anybody currently drafting this legislation have personal experience of challenging a local authority when trying to deliver a service? If the Minister would find it helpful, I would be willing to share our considerable experience in this area and explore together how we might make this piece of the legislation workable in practice.

To call attention to the case for policies to support economic growth and to promote investment, innovation, technology, infrastructure, skills and job creation; and to move for papers.

6 April 2011

I suggest that the big society depends on micro businesses as exemplars to lead the way.I therefore request that the Minister actively explores practical ways to identify, promote and foster economic growth within this emerging entrepreneurial sector across the UK. Much of it is based in some of our most challenging communities. The social sector is formed from many shoots and distinctions need to be drawn to protect these young entrepreneurial flowers. Will the Minister please inform the House how the Government plan to empower social enterprises in some of our most challenged communities?

Reorganisation of the NHS

21 December 2010

How in practice is government going to use the restructuring of the health service to create a new narrative relevant to modern health? Secondly, what is government going to do to ensure that doctors engage with innovators and entrepreneurs?

Speech to the House of Lords 28th October 2010

4 November 2010

My Lords, I want to make a few points about health and social care. How do we provide quality healthcare that meets the real needs of patients in today’s world? Will the popular biomedical model of health meet all those patient needs, or does its internal logic present us with a limited view of what [...]

Health: Primary and Community Care Debate 24th June 2010

25 June 2010

Lord Mawson:My Lords, it is a privilege to be able to lead this debate on the future of primary and community care at this early stage in the new coalition Government. The vision that the Government have set out for primary care, where resources are deployed in the hands of practitioners close to the ground, [...]

Education, Health, Welfare, and Culture – 3rd June 2010

4 June 2010

Lord Mawson: My Lords, I should like to add to the deluge of praise. I congratulate the new Government on their success and wish them well in the coming years as they try to develop a working partnership and deliver their programme. I also want to take this opportunity to wish the Minister, the noble [...]

The Use of Church Buildings – 22nd February 2010

25 February 2010

My Lords, there are nearly 50,000 church buildings in England; 16,200 of them belong to the Church of England, and the rest are mostly owned by the Catholic Church, the free churches and other denominations. Many sit on prime sites at the centre of their communities, yet they are often large and underused.

Queens’ Speech – 23rd November 2009

25 November 2009

I have a bit of a reputation, I think, as a moderniser of public services and for taking outdated health and education systems and applying to them entrepreneurial thinking and practice. My colleagues and I, both in east London and nationally, have produced results over the past 30 years which demonstrate some success. At the core of this work has often been the empowerment of disfranchised local communities and individual citizens so that they might take more responsibility for their personal lives and families and their local community. This is what citizenship is all about.

Healthcare – June 25th 2009

14 October 2009

The poor souls in the third sector are no third-rate choice. The third sector is like any other sector—better in some places than others. Our approach to procuring health and social care services is ignoring some of the most talented and innovative individuals and organisations—people who have been working tirelessly in their communities for far longer than the perennially reconstituted PCTs and health authorities.

Olympic Legacy 18th June 2009

18 June 2009

Lord Mawson: My Lords, I, too, thank the noble Lord, Lord Coe, for leading this important debate. It is a very helpful time to have this discussion, because a great deal has happened during the past year and new opportunities are now presenting themselves, which allow us all to move on and to deal with the [...]

Housing and Regeneration Bill 23rd June 2008

23 June 2008

Lord Mawson: I shall speak to Amendments Nos. 113B and 113C. A well conducted ballot is widely thought to be the best way to interpret existing transfer legislation. The proposal is now to write the requirement for a transfer ballot more directly into the Bill. The value of ballots is hard to argue with, but it [...]

Housing and Regeneration Bill 16th June 2008

16 June 2008

Lord Mawson: The key point that I was attempting to make before I was interrupted by the Division Bell is that the housing association movement was begun by social entrepreneurs of their day who used their independence from the state to begin to pioneer new and innovative ways of creating social housing. The capital development programme [...]

Housing and Regeneration Bill 11th June 2008

11 June 2008

Lord Mawson: Amendment No. 104ZA seeks to encourage the Minister and her colleagues to look carefully at how the large amount of money which they are about to invest in housing can be used as a trigger to encourage social innovation. The housing association movement was begun by social entrepreneurs of their day, who used their [...]

Housing and Regeneration Bill 19th May 2008

19 May 2008

Lord Mawson: I shall speak to Amendment No. 23A, which is in my name and is part of the group. It is a probing amendment, which recognises that the creation of the Homes and Communities Agency presents us with a real opportunity to move away from public housing monocultures of the past and to invest in [...]

Housing and Regeneration 13th May 2008

13 May 2008

Lord Mawson: I, too, welcome the amendment. Since I entered your Lordships’ House I have been very encouraged by the concern about quality of design. I was very encouraged by the debate, which I could not attend but which I read, in which the noble Lord, Lord Howarth, spoke, on the quality of design. One can [...]

Housing and Regeneration 28th April 2008

28 April 2008

Lord Mawson: My Lords, I, too, welcome what I perceive the Government are attempting to achieve in this Bill. The creation of the Homes and Communities Agency could have enormous potential and be a key delivery partner in building successful communities. The aspiration behind this legislation is laudable and presents enormous possibilities for the investment that [...]

Arts and Healthcare

6 March 2008

The key question is: what does it mean to be a healthy and fully rounded human being and what kind of services do we need that will help, rather than hinder, such human development?

Olympic Games 2012: Legacy

17 January 2008

Lord Mawson rose to call attention to building sustainable communities and securing a worthwhile legacy for the London Olympics; and to move for Papers.

Maiden Speech 20th June 2007

20 June 2007

Lord Mawson: My Lords, as I rise to make my maiden speech I am conscious, as the son of a milkman from Bradford, of both the privilege and the responsibility of taking a seat in this place. I take this opportunity to thank those noble Lords and staff who in the past few weeks have helped [...]