The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)
My Lords, first, I thank the noble Lord, Lord Turnberg, for bringing this debate, and I thank the 45 people who have contributed to it. That shows that the noble Lord has touched an important nerve. The future of the health service and of social care in this country is hugely important.
The noble Lord, Lord Turnberg, talked about his experience at Salford, where they have a fantastic hospital with a joined-up system. This shows that it can be done. Around the country, there are hospitals and healthcare systems that are doing it; they are doing a fantastic job by good standards. Of course, that requires great leadership, and leadership is not something that can be cloned; there just are not that number of great leaders in any system. However, in Salford, under David Dalton, they have a great leader.
The fact that it can be done lies behind the work that the noble Lord, Lord Carter, has done. Hospitals around the country are achieving great performance. However, the noble Lord, Lord Carter, has uncovered a huge amount of what he would call “unwarranted variation”; that could be unwarranted clinical variation, operating variation or any other kind of variation. That has to be addressed, and the noble Lord, Lord Carter, has given us a methodology for doing that. He, along with other noble Lords in this debate, points out that unless we can crack delayed discharges in hospitals and delayed transfers of care, many of our hospitals are going to struggle.
I also pay tribute to the noble Baroness, Lady Watkins. In her maiden speech she very properly reminded us of the importance of training and community-based services. Her mentor, the noble Lord, Lord Patel, who was watching as she gave her address, is no doubt watching me from India as I speak to the debate.
I want to mention two particular contributions. The first is the speech by the noble Lord, Lord Winston. The noble Lord, Lord Hunt, picked up on his point about academic medicine. That is a crucial issue and one that I cannot address head-on today, but perhaps we might have a meeting involving others, including Hugh Taylor, to talk about it further. The second is the contribution by the noble Lord, Lord Mitchell, about the contrast between his son, who is a junior doctor, working in England compared to working in New York. I thought that that was a very revealing contribution, if I may say so.
I want to preface all my remarks by paying tribute to not just junior doctors but to all those who work for the NHS and in social care. They do an extraordinary job and have a true vocation, and many noble Lords have experienced the benefit.
This is the third general debate that we have had on the NHS since the election. The first was introduced by the noble Lord, Patel, and the second by the noble Lord, Lord Crisp. In that debate, we talked very much about prevention. We could be here for many hours talking about prevention. The noble Lord, Lord Rea, talked about the importance of housing and employment, and there are so many other issues that we could talk about in the context of prevention. Therefore, I hope that noble Lords will excuse me if I do not address prevention as much as they might like me to.
I want to go back to June 1948 for a minute, and to Nye Bevan talking to the Royal College of Nursing. He said:
“We shall never have all we need. Expectations will always exceed capacity. The service must always be changing, growing and improving—it must always appear inadequate”.
The noble Lord, Lord Desai, made the point that when you have a service that is free, demand will always exceed what we can provide. Nye Bevan saw that back in 1948, and it is important to hold on to that when we look at our funding situation at the moment.
We do have a plan: the NHS Plan. The NHS Five Year Forward View was produced by Simon Stevens of NHS England and supported by all the arm’s-length bodies. It is not the Prime Minister’s plan, it is not my plan and it is not the Secretary of State for Health’s plan. It is the NHS’s plan. It called for £8 billion of real investment over that five-year period, and the Government have given the NHS that amount of money: it is £16 billion in cash terms and £8 billion, or arguably £10 billion, in real terms. This is broadly what the NHS wanted.
The NHS is actually doing quite well. I will come back to some areas where it is not doing as well as we would like but, broadly speaking, it is doing quite well. The Commonwealth Fund said that it is first overall compared with other OECD countries, scoring highest on quality, access and efficiency and second on equity. In the recent Economist review looking at end-of-life care, we came out top. However, that is not perfect. The noble Lord, Lord Freyberg, pointed out that our cancer outcomes are not as good as they should be. The noble Lord, Lord Bradley, talked about mental health, and clearly we can do better there and in other areas too. There is too much variation in what we do. However, if we look at medical research, the quality of our education in most of our medical schools, medical publications and clinical outcomes, the NHS can still be regarded as a world-class health service.
Other noble Lords have already made the point that we do this at very low cost. In America, they spend 16% of GDP on healthcare; we spend around 8% and most of Europe spends around 10% or 11%. We do it at very low cost and we get very good results. On that basis, when people say that it is not affordable—an issue my noble friend Lord Fowler and others have raised in this debate—I say that it is affordable. We are doing it at 8% of GDP at the moment but we could choose to spend 10% or 11%: the country can afford good healthcare. I would argue that we are providing good healthcare at the current level of spending.
There is no evidence that a tax-funded system is any less efficient or effective than other systems of funding healthcare. Indeed, I would argue that, on the contrary, the NHS, for the reasons that I have given, is an efficient system. The OECD made a more neutral comment, saying that,
“no broad type of health care system performs systematically better than another in improving the population health status in a cost-effective manner”.
Therefore, I do not think there is an argument for questioning whether we can afford a good healthcare system in this country.
I turn to the various questions that were raised. Is it affordable? Yes, it is affordable, and we are demonstrating that. Is a tax-funded system viable? Yes, it is viable, and I will go further and say that there is evidence to suggest that it is more viable than any other way of funding a healthcare system. Do we have a viable plan in this country? Yes we do, and I will come to that in a minute. Do we need another plan or another commission? I do not think we do. It would be an enormous distraction at a time when we have a five-year forward view. At a time when the whole of the health service is committed to that view, there would be immense concern if we embarked on yet another review or commission of any kind. We would go through a two-year hiatus waiting for that report and would not be able to get on and deliver what we have at the moment.
What is that plan? It falls into two parts. First, can we make the existing system more efficient? The answer is: of course we can. We have some of the best hospitals, wards, clinics, laboratories and specialties in the world in the NHS. Our problem is that there is so much variation across the system—clinical variations, staffing variations, property utilisation variations, procurement variations, pharmacy and medicines utilisation variations and back office costs variations—all of which have been identified, as shown by the extremely important work done by the noble Lord, Lord Carter, assisted by clinicians such as Professors Tim Briggs and Tim Evans. They have given us an improvement methodology based on transparency which will deliver huge improvements over the next five years. A great deal of their work is mirrored on commissioning through the use of the Right Care programme and the Atlas of Variation that has been developed largely by Dartmouth in the USA.
The second part of our plan concerns the new models of care—an issue raised by the noble Lord, Lord Turnberg—and we have already seen these operating effectively in Salford.
This is a move from institutions to systems. We are now trying to develop a place-based care, a population-based care. Although there were many benefits from foundation trusts—I believe wholly in the principle of earned autonomy—one of their unintended consequences is that they have created a fortress mentality in some parts of the country. The King’s Fund has used the analogy of the tragedy of the commons, where everyone is looking after their own interests rather than the interests of the wider system. It has also left patients having to navigate a complex, unjoined-up series of different organisations. We will see over the next four or five years the emergence of new systems of care, including PACS and MCPs, and the Accountable Care Organisation, ACO, will become increasingly familiar to us.
We will also see different outcome-based payment systems and incentives as we move to integrate with social care. There will be many cynics and sceptics because some people, as the noble Lord, Lord Turnberg, said, have seen all this before. We have been talking about integrated care for 20 odd years. I think it is different this time—but I would say that, wouldn’t I?
We have to ask why change is so difficult in healthcare—and not only in the NHS. Why has there been such dramatic change in car manufacturing and retailing across the world, when healthcare systems have proven much more difficult to change? Interestingly, in the 2000 NHS plan, echoed in the five-year forward view, were two comments: that we have a 1940s system delivering care to a 2016 population with entirely different needs to the population of 1948; and that healthcare has been slow to move, not only in the NHS but around the world. Changing that system will be difficult but very important.
Why am I optimistic about it? First, we have a narrative. The five-year forward view gives the whole service a very powerful narrative around which it can combine and work together. Secondly, the architecture of the system is not perfect—I know that the noble Lord, Lord Lansley, is sitting behind me—but it is serviceable. We do not need another top-down reorganisation. We can work with the bodies created through the last reorganisations, and NHS England is now building resources and a team of people who can truly deliver on its plan. The new purpose of the NHS is based around improvement and learning rather than regulation, which is important, and the independent CQC.
There are two other reasons for optimism. Transparency will be a much better improvement mechanism than targets, regulation, competition and the command and control structures that we have had in the past. The financial crisis we have gone through has made hospitals look more radically at how they can change their models of care. Finally, we have not spoken in the debate today about the huge impact that technology will bring in empowering patients to look after themselves and take greater personal responsibility, as other noble Lords have mentioned.
I have to conclude. I thank the noble Lord, Lord Turnberg, for introducing this fascinating debate, which has raised important issues. I look forward to reading it in the cold light of day over the weekend.