My Lords, I should like to speak to the amendment proposed by my noble friend Lady Hodgson.
From the age of five, I was a child of general practice; it was my world. I accompanied my father on home visits, patients came to our house and the telephone rang constantly—my mother was the secretary and took all calls. My father loved his patients and they loved him. He knew them inside and out, and their families as well. He attended road traffic accidents, of which I have to say there were plenty, and he delivered babies at home—he never lost one. I remember him telling me one day when he came back from a birth that it had been a very difficult birth, but the mother praised my father for having helped her to produce a very healthy little boy. “Doctor”, she said, “we will call the baby after you. What is your name?” My father replied,
“Lambert”. “Right”, said the father, “we will call our son Tom.” I mention this only because maternity has been the love of my life, and in this area relationships are critical to a safe and good experience. In my youth, maternity was part of general practice.
After being appointed much more recently to chair the maternity review for England by Simon Stevens—as he was then; now, of course. the noble Lord, Lord Stevens of Birmingham—I was determined to introduce relationship care, sometimes called “continuity of carer”, where the final “R” stands for relationship. We have much respected and credible research from the Cochrane Collaboration in Oxford which shows that women who receive relationship care are less likely to have a preterm birth, less likely to lose their baby before 24 weeks and less likely to lose their baby overall.
We now have in the NHS 371 relationship teams with 2,355 midwives in place where the midwife provides all three elements of midwifery care: prenatal, birth and postnatal care, which is sometimes called follow-up care. In the James Paget Hospital, 90% of maternity care is provided through continuity and it has a waiting list for midwives to join the hospital. Through this initiative, we are transforming maternity care. The women and their families value hugely the relationship with their known midwife, and the midwives who are providing this care absolutely know that what they are doing is the right way to work. They would leave their hospital and go to one that provided such care if their hospital gave it up.
Listening to my noble friend Lady Hodgson, is not this what she seeks for general medical practice? Her amendment is well drafted and reflects an interesting report produced by the Royal College of General Practitioners, entitled The Power of Relationships: What is Relationship-based Care and Why is it Important? and published in June last year. In his foreword, Professor Martin Marshall, chair of the college, writes:
“COVID-19 has radically changed the face of general practice. We have moved from a predominantly face-to-face service to one in which most consultations are delivered remotely, either by telephone or video call … Remote consultations are certainly here to stay. For many patients, they enable quicker and more convenient access to a GP appointment, which of course is hugely important.”
But then he asks the following questions:
“But should speed and ease of access be our primary measures of effectiveness? They are certainly easier to quantify. But what about the quality of care? What about the relationship between doctor and patients which, to me, is the essence of general practice?”
He goes on to say that
“The evidence for the benefits of a trusting relationship is compelling—better patient experience; better adherence to medical advice, fewer prescriptions, better health outcomes, better job satisfaction for doctors and even fewer deaths.”
Indeed, he says that the relationship between the patient and their GP is as important as the scalpel is to a surgeon:
“If relationships were a drug, NICE would mandate their use.”
6.15 pm
This is a very compelling and well-researched document. It goes with the grain of modernising general practice. General practice does need modernising. We need to make it more interesting and more satisfying to fulfil the vocation of young doctors and to meet the needs of patients now and in the years to come.
The world is certainly not the same as it was in 1948, when the NHS was designed. Some things are still true, such as GPs needing to be able to fulfil the holistic role for the patient. To do this today, they need access to diagnostics. They also need specialist help in the community from consultants and, on occasions, a network of support from nurses, physios and other health professionals.
Hospitals are now more specialised. There are fewer of them, and they serve much larger populations than they did in 1948. As the noble Lord, Lord Crisp, reminded us in an earlier debate, “Health is made at home; hospitals are for repairs.” If one is to believe the headlines in last week’s Times, GPs will be “nationalised in Javid plan to reduce hospital admissions.” Was this really a power grab by a hospital to take over general practice? I do not believe the headlines, but we need flexibility if primary care is to flourish—even to survive. A scheme in Wolverhampton had fired the imagination of the headline writer, but he did not explain that, in this area, practices were struggling. One or two were failing and one or two could not survive. If the patients wanted to keep a local primary care service, something had to be done. I understand the scheme, whereby GPs are linked to and employed by the hospital. It required a huge amount of work by its leaders—the hospital managers and the GPs, who needed to be convinced. They needed to be assured that it was in their interest to agree to a scheme which would work for the benefit of patients and of all those providing a service. The idea that this could be rolled out nationwide is simply erroneous. In other areas, it has not worked well. Patients feel that they have been denied a choice of hospital care. Hospitals have refused to refer patients to GPs when the hospitals are not busy. Out-of-hours has collapsed.
All of us, in this Chamber and outside, are for ever saying that one size does not fit all—of course it does not. As Andrew Mawson—the noble Lord, Lord Mawson —has taught us, every community is an entity with its own history, geography and personality. We should respect that.
Since my father’s time, much has changed in general practice. There are no night visits, no weekends, no accidents and no births. The preference is for living away from the practice area. A GP is available 40 hours a week, with the majority opting for part-time work. For the other 128 hours? Well, ring a number or go to A&E for excellent medical care. When the Royal College of GPs says that the prime duty of a doctor is triage, why bother to go to the GP when you are ill? Cut the triage. Go direct to the hospital where diagnosis and a prescription will be made. Once that has happened, follow-up care can be done by a nurse prescribing a regime. But we do not want that. We want to learn from the best of general practice, general practice prepared to give a full service with total commitment to its patients and a valued relationship. The good news is that there are many like that across the country. There are remarkable GP practices in tune with the communities they serve—inner-city, suburban, coastal, deeply rural areas that are isolated but resilient, isolated but vulnerable—