Mr Nick Clegg (Sheffield, Hallam) (LD)
I join all those who have spoken so far in congratulating my right hon. Friend the Member for North Norfolk (Norman Lamb) on securing the debate. It concerns what is undoubtedly one of the biggest questions that we face as a country, as a Parliament, and as a political class: the question of how we can square the circle of an ageing population, and how we can put the NHS on to a sustainable financial footing.
My grandfather was editor of the British Medical Journal from the time when the NHS was founded until the mid-1960s, and I suspect that if he were around today, he would say that the challenges currently faced by the NHS would be entirely unrecognisable to his generation of medics.
It is right that my right hon. Friend is pushing us all to try to sketch out solutions on a cross-party basis. It could be said that he and I tested the virtues and pitfalls of cross-party working to destruction—some would say, unfairly perhaps, to self-destruction—in the last Government. Notwithstanding that experience, however, I think that issues such as pensions, long-term infrastructure investment, Europe, decarbonisation of our economy and, in this context, the sustainability of the NHS are not susceptible to single-Parliament, single-Government, single-party solutions. I therefore say, “All power to my right hon. Friend’s elbow”, and I hope that the Government will look kindly on his proposal.
I intend to dwell on an issue which I hope the commission will subject to real examination, namely the role of mental health in the NHS. We have come a very long way. I remember standing, eight years ago, a little way in front of where I am standing now, shortly after becoming leader of my party, and asking Gordon Brown a question about mental health during Prime Minister’s Question Time. I recall that I was heard in what was almost a slightly shocked silence, because at that time raising the subject of mental health was considered to be rather “novel” and brave. The extent to which the debate has advanced since then is fantastic.
There have been truly moving debates in the Chamber, when a number of our colleagues have spoken for the first time, very openly and movingly, about their own struggles with mental health conditions. Society and the media now talk more comfortably about mental health, and a barrage of celebrities have lent their considerable weight to that. The debate, the rhetoric, and the awareness of mental health as a major challenge that affects one in four of our fellow citizens have been transformed in recent years, which is a wonderful development. We have lifted the lid, lifted the taboo, and lifted the slight foot-shuffling embarrassment that used to overshadow the subject of mental health, which is a great step forward.
I am immensely proud of some of the things that our coalition Government managed to do in pushing the agenda forward and putting mental and physical health on the same legal footing. My right hon. Friend and I worked together closely on the introduction of NHS waiting time standards relating to mental health, which had existed in relation to physical health issues for a long time, and took many other important steps.
What worries me is the growing gap between the rhetoric about mental health and the reality of what is happening on the ground. There will always be a gap, because rhetoric is easier to deliver than change on the ground; there will always be a time lag between the moment when the debate and the policy prescriptions alter, and the moment when that change percolates down to the ground. However, I think that this gap is becoming dangerously wide. That is, of course, very bad for the many patients with mental health conditions who are not being properly treated, but I also think that if we do not address it soon and follow up the rhetoric with action, there will be real cynicism about what the political classes have meant during the journey that we have made over the past few years towards talking more comfortably and openly about mental health issues.
I know that many Members are already familiar with the scale of the problem, but I think it worth illustrating that scale with a couple of facts. Mental health makes up 23% of what is somewhat inelegantly described as the UK disease burden, but it accounts for only 11% of NHS spending, and the majority of people with mental health conditions still go untreated. On average, just 30%—less than a third—eventually gain access to treatment. If that applied to any physical health condition, it would be seen as a Dickensian state of affairs requiring urgent action. I hope that the cross-party commission will think carefully about the step change that is required in the organisation, because support and funding for mental health will be critical to its considerations.
Let me now invite the Minister to focus on three issues, in the short term and in the slightly longer term, because I think that there is currently a blockage that is preventing the rhetoric from being translated into the kind of action that most Members on both sides of the House want to see.
The first issue is that, last year, just before the last Budget of the coalition Government and the general election, I announced, on behalf of the Government, £1.25 billion in funds to transform what could be described as the Cinderella service within the Cinderella service, namely child and adolescent mental health services. It was the most ambitious blueprint ever set out by any Government to transform the service and, indeed, to fund it properly. As the Minister will know, that £1.25 billion equates to roughly a quarter of a billion pounds, or £250 million, to be invested in child and adolescent mental health services per year. Over the last financial year, however, the amount invested has been not £250 million but, I think, £143 million.
The Minister for Community and Social Care (Alistair Burt)
It was about £170 million.
Mr Clegg
I stand corrected. Anyway, it was not £250 million.
There may be perfectly explicable teething problems. The announcement was made in the spring of last year, and it will have been necessary for all the mental health trusts to shift gear. However, I hope that the Minister—or, if not him, the commission—will ensure that not only future mental health reforms but previous commitments are delivered and funded in full. The £250 million that has not been delivered over the last year needs to be made up for between now and the end of this Parliament.
My second point concerns the importance of prevention —in all areas of health, obviously, but perhaps especially in mental health. The need for better prevention measures was one of the key findings of the mental health taskforce’s public engagement exercise, yet there has been little if any mention of it in recent Government announcements. Mind, the mental health campaign and policy group, has established that local authorities spend just 1% of their public health budgets on the prevention of mental ill health. That is £40 million out of a total budget of £3.3 billion. Yet we all know—even if we are not clinical experts, we know as parents, and as human beings—that intervening early to improve child and adolescent mental health avoids so much illness, so much heartache, and, to be candid, so much cost to society thereafter. Half of those with lifetime mental health problems first experience symptoms by the age of 14, and 75% of children and young people who have a mental health problem do not get access to the treatment they need.
Waiting times are still far too long. Average waiting times for CAMHS is two months—and as yet there are no waiting time standards in children, adolescent and mental health services. I think we all know, and I certainly accept it, that as we try to revolutionise the approach to mental health, the waiting time standards that have already been announced need to be spread and extrapolated to other parts of the service. Members have talked about the need to reconcile and bring together social care and healthcare, and if we want to put the NHS on a financially sustainable footing, which is the purpose of the cross-party commission, we also need to understand that the lack of prevention and of early intervention on mental health problems is one of the biggest drivers for subsequent inflated costs on the NHS budget. It is therefore essential that the commission looks at this as well.
Thirdly—and arguably most importantly, and also perhaps most technocratically complex—is the issue about the formula or mechanism by which mental health is funded. The problem is that for as long as anyone can remember mental health trusts have been funded according to block grants, through a lump sum of money given to them by some varying formula, while other NHS trusts—acute trusts—are paid on a per patient, per outcome, per recovery basis. That of course is deeply unfair, because it means that any time any Secretary of State for Health, Chancellor or NHS boss needs to make savings, the easiest thing to do is quietly shave a little money off that block grant, as no one really notices it —it does not stick out like a sore thumb like other financial cuts do—and that is precisely what has been happening. That is one reason why—even in recent years, however much new and welcome emphasis there has been on the priority mental health should have in the NHS—the basic funding formula or mechanism constantly discriminates against mental health trusts.
The Minister for Community and Social Care (Alistair Burt)
This has been a really great afternoon. I have thoroughly enjoyed listening to all the speeches. It has been the sort of debate that I think people outside this place appreciate. I thank the right hon. Member for North Norfolk (Norman Lamb) and his colleagues for securing the debate. I also thank him, as always, for the contribution he made when he was in the role I am now in. I thank all right hon. and hon. Members for their contributions, not least those with a medical background. We encourage them to remain in active medicine, because it brings an extra dimension to these debates. If I have time, I will address the comments from each Member. I will first respond briefly to the nub of the debate before responding to colleagues’ remarks and making some comments on the structure.
The sustainability of the NHS and social care system, whether financial or operational, is a key commitment of this Government. However, we do not believe that there is a need to launch an independent commission into its future. The NHS and wider health system has already examined what needs to be done to ensure the sustainability of the health and care system. Part of the purpose of making NHS England independent was to allow it to examine the circumstances of its finances and project into the future. It did so independently and came up with a figure. The Conservative party, uniquely, met that commitment at the last election and was able to carry it into government. It is important for the House to recognise that right at the beginning.
Norman Lamb
I just want to challenge the Minister on the suggestion that NHS England came up with the figure and the Government met it, because that is not actually what happened. NHS England and Simon Stevens painted three scenarios. The scenario that the Government have met, and on which both my party and his party stood at the election, is based on assumptions that are heroic in their scale and have never been met in the history of the NHS.
Alistair Burt
If I may say so, Simon Stevens said, “Look, it needs £8 billion.” It also needs £22 billion in efficiencies. We have met the challenge and put in even more than £8 billion—by 2020 it will be £10 billion. I understand the pressures in the system and fully appreciate the right hon. Gentleman’s remarks. The King’s Fund stated in its 2015 report:
“‘Business as usual’ is not sustainable. But that does not mean the NHS is fundamentally unsustainable.”
Simon Stevens recently said:
“The NHS has a huge job of work to do ensuring an already lean health service is as efficient as it can be—which, in my assessment, people are entirely up for.”
He recently told the Health Committee, “In headline terms, £22 billion is a big number, but when you think about the practical examples and do the economic analysis, we have some pretty big opportunities in front of us.” We know that the challenge is there; nobody denies that. However, NHS England put its assessment of what it needs to the political parties at the last election. We met that challenge and were elected.
We have spoken about a process, and I will return to that in a moment. What NHS England produced was developed by it, along with Public Health England, Monitor, Health Education England, the Care Quality Commission and the NHS Trust Development Authority. The Government back the plan, but we need a strong economy to be able to do that, as a number of colleagues have said. Without trespassing too much into other areas, that is the meat of political debate in this country. The public are not just asked to make a judgment on the delivery of one particular service, however precious it is. It is about whether they think that those who are promoting their view of a particular service have the economic background to deliver it. That question was also comprehensively answered at the general election. We now have responsibility for carrying that forward. People believed that we could put the money into it, and we have done so.
Liz Kendall
The Minister says that he believes that the Government have met the challenge, so does he think, with regard to funding the NHS and social care, that it is job done?
Alistair Burt
I said that we have met the challenge that was put before us, which was to support what NHS England said it needed. We have done that through the financial commitment we have made. We looked very hard in the spending review to see what social care would need, and the Chancellor came up with the £2 billion social care precept, plus the £1.5 billion from other resources, so that is £3.5 billion extra by the end of 2020. We have put in place the financing that we believe will allow the delivery of health and social care over the next few years. But—and it is a big but, which I will refer to later—it is not just about the resources; it is also about how they are spent. Most colleagues have spoken about variability and how best practice is not always available elsewhere. We have to ensure that best practice comes in, and that is not just about resources; it is also about how things are done.
Dr Philippa Whitford
Is it not the case that the idea of seven-day-a-week, 8 am to 8 pm GP practice was not included in the NHS England estimates, and therefore the cost of that has been added on top? Will the Minister commit to taking the evidence from the pilot studies on whether that is a good use of money?
Alistair Burt
I will. We had this discussion in the Health Committee the other week. I will of course look very hard at the evidence, whether it comes from Greater Manchester and shows that somebody is working effectively and appointments are being filled, or from places where that is not currently the case. We have to wait and see in that regard.
The spending review showed our continued commitment to joining up health and care by confirming an ongoing commitment to the better care fund. Again, the integration process is extremely important. In terms of the general argument about what should be done, a clear commitment was made, based on an independent assessment of what was required. That required a Government who were prepared to make difficult decisions, and a strong economy, and we assumed that responsibility.
Let me deal with some of the remarks made by right hon. and hon. Members during this conversation—for it is, as the hon. Member for Central Ayrshire (Dr Whitford) said, a conversation, and a really good one. If more debates about health had the flavour of this afternoon’s discussion, the public might be happier. She said that her preferred method for dealing with things, as with most of us, is bringing people into the same room and having a conversation—but perhaps not this room. However, there are other rooms in this place in which to do that. Indeed, my hon. Friend the Member for Totnes (Dr Wollaston), the Chair of the Health Committee, does so regularly. This place can provide opportunities for the sorts of discussions that would be at the heart of any cross-party consideration of what we want to do. We should not neglect the fact that we can do that, and we have had a good conversation today.
I agree with the hon. Member for Lewisham East (Heidi Alexander) in that I am fundamentally shy of the idea that we can just put this on to others and with one bound we are free. I understand the sentiment that we somehow need to get, if not the politics, then the heat of the politics, out of it in order to allow for the conversation that we need to have. However, at the end of the day, that still requires a process. Like her, I believe that the process is that we discuss it, come to conclusions within our own party about what we can do, and offer it in a sensible way to the electorate. I entirely agree with those who say that there are times when we have all been guilty of the most ridiculous adverts. At the end of the last general election campaign, I was in a marginal constituency and had a piece of paper in my hand that was our last-minute leaflet. I knocked on doors and said, “Look, we have a choice—I can either hand you this leaflet, which is complete nonsense, or you can give me 20 seconds to explain why you should vote for David Cameron tomorrow and keep a Conservative Government.” They laughed and said, “Go on, then”, and I had my 20 seconds. We all know that we are sometimes guilty of producing material that in the cold light of day we would not wish to, and in relation to health we need to be extra-careful about that.
As the debate went on, I was concerned about whether the commission that the right hon. Member for North Norfolk and his colleagues is proposing can bear the weight of the many different things that we would like it to cover. My hon. Friend the Member for Totnes wanted it to report rapidly, but my right hon. Friend the Member for Sutton Coldfield (Mr Mitchell) intervened to say that it had to be for the longer term, so which is it to be? My hon. Friend also spoke about the problem of variation in the system, but that is not to do with resources. No commission could be so directive as to make sure that best practice is delivered everywhere. We have to do that in another way.
The hon. Member for Leicester West (Liz Kendall) in, as always, a very thoughtful and sensible speech, recognised the political problem in agreeing on this, and she was right to do so. It is very difficult for her, or any other Labour Member, to talk about the introduction of private medicine. If I did not stand here and say, with no deviation, that the Conservative party and the Government believe in a tax-funded health system free at the point of delivery, the roof would fall in. Therefore, there are constraints on what we can say politically, and we have to be thoughtful about how we deal with those responsibilities.
My hon. Friend the Member for Bracknell (Dr Lee) added more weight to the commission by talking about structure, and how we deal with these reviews of where hospital premises might be located. Again, there is this problem of politics. When approached by patients or doctors with a vested interest in keeping a physical bit of bricks and mortar and in saving “our” hospital, it would be a brave one of us who said, “Do you know what? That may not be the best thing.” That difficult problem was alluded to by my hon. Friend the Member for South West Wiltshire (Dr Murrison). No commission can get us over that sort of problem.
The hon. Member for Strangford (Jim Shannon) invited me to Northern Ireland to see some integration at work, and I would be keen to visit. My hon. Friend the Member for South West Wiltshire and a number of colleagues made the point about public health. Prevention is about not just the public health budget—significant resources are still going into public health—but what we are trying to do with the shift from secondary to primary care to ensure that people are seen earlier.
The hon. Member for Central Ayrshire talked about ensuring that we keep people well longer. She said that instead of seeing the national health service as an organisation that looks after just the ill, we should consider what it can do before that, which is very important.
The right hon. Member for Sheffield, Hallam (Mr Clegg) spoke principally about mental health. As a Health Minister, I know full well what the coalition Government as a whole did in relation to mental health. They picked up a trajectory that had been disappointingly low, but we are now well on track. I wish gently to correct something that has been creeping into the narrative, which is that it was all going fine until six months ago, but it has slightly come off the rails now. It has not. It was not all sorted during the coalition, and I reject the charge that it is now all about rhetoric and not delivery. We are delivering, and making sure that CCGs spend the increased money that they get on mental health, and we are tracking it for the first time.
That £1.25 billion for children and young people’s mental health, which was a very significant delivery by both the right hon. Gentleman and the coalition, has been increased to £1.4 billion, and it will all be spent in that area by 2020. We are dealing with the issue of mental health tariffs as well, and we want to have waiting and access times for children and young people’s mental health services.
I encourage the right hon. Gentleman to see, at least in this part of my portfolio, that what I seek to do is to build on what the right hon. Member for North Norfolk did in my role. I would rather that the right hon. Member for Sheffield, Hallam did not talk in that manner and think that it has all come to a halt, because it has not. We are having to repair one or two things, such as perinatal mental health, in which we have put significant resources. The conversation has been advanced enormously in exactly the right way by consensual discussion, and we will certainly carry that on.
Mr Clegg
The right hon. Gentleman is being a little over-sensitive. I bent over backwards to say that it is entirely understandable that there is always a lag of time between rhetoric and delivery. All I will say, in the most consensual, cross-party, non-finger-pointing way, is that there is a real delay now between the pilots that were started back in 2012 and the paucity of the number of mental health trusts that have placed their financial arrangements on the new non-block grant system. That is the urgency with which we must deal.
Alistair Burt
I accept that. I was not in this post in the period from 2012 to 2015. I am certainly ensuring that we are progressing. I am glad that we have sorted that out. The coalition’s involvement with and commitment to this issue have been immense, and I am very proud to carry that on in the way I am doing.
My hon. Friend the Member for Lewes (Maria Caulfield) brought her experience to this debate. She spoke about the integration of budgets for social care and for local authority expenditure in the national health service, which is absolutely crucial. For me, integration is not about getting two groups of people to sit down in the same room every few months or so to have a discussion. It really cannot be done without a combined budget. So long as there are perverse incentives for one budget or another, it will not work.
We are making progress on that and have clear plans to get it done by 2020. We will follow our progress with a scorecard to find out where we are. We have spoken for too long about finding the holy grail, but we are further towards it than anyone has been before. That is not a bad place to be, but we must ensure that we make progress. A lot of this is about relationships; it is not just about organisations being in the same room. Unless people really talk to each other and have a real sense of what can be done collectively, we will not get anywhere.
My hon. Friend made the heartfelt plea, “Leave us be from time to time.” That would certainly be echoed by virtually everybody I have ever been involved with in the public sector during the past 30 years. They just wish we would decide what is to be done and let them get on with it for a while before changing it again. I am quite sure that this Government have absolutely absorbed that lesson.
The hon. Member for Don Valley—[Interruption.] Will she forgive me? Once I have been in the House for a few years, I will get all such distinctions right. The right hon. Member for Don Valley (Caroline Flint) speaks from a position of great experience and great success. She spoke about the successes and the failures in the system, which we all know about, and about how the commission could look at them. Again, I am not quite sure that it could bear the weight of doing so.
The right hon. Lady addressed the political issues and how difficult some of them are. If she will forgive me for saying so, she made an intervention on the hon. Member for Oldham East and Saddleworth (Debbie Abrahams) that exemplified the point. There are difficult political challenges within parties as well as between parties across the Floor of the House, and I noticed the little challenge that was made.
I must say to the hon. Member for Oldham East and Saddleworth, who spoke with great passion about her party’s commitment to a publicly funded or taxpayer-funded NHS with no deviation from the line, that that is simply not true. It suits her to say it, but it is not true. Let me quote from an article from the New Statesman of 27 January 2015, under the headline “Labour can’t escape its Blairite past on the NHS, so it should stop crying ‘privatisation’.” It said that Alan Milburn
“serves as one of many reminders that not so long ago, during the New Labour years, the Labour party was driving through dramatic reforms in the NHS and did not shy away from private money in doing so.”
There are variations on a theme, even for the hon. Lady, and she perhaps protested about the public nature of the NHS a little too much.
Debbie Abrahams
I am grateful to the Minister for giving way as he did not challenge me when I made that point. Does he, however, accept that Labour stood on the platform of saying that the NHS should be the preferred provider? As other hon. Members have said, we have learned how important it is that policy driving the NHS should be based on evidence. We now have evidence that a health system with an internal market, or a marketised or privatised health system, which is what this Government are seeking, does not help to improve quality or to reduce inequity in healthcare. That was our platform.
Alistair Burt
Well, the platform was clearly stunningly successful. I am not embarrassed by being reminded of the Labour party’s NHS platform at the last election, because it did not succeed. For one reason or another, the public did not believe the stories run about us and the NHS, and they did not believe in Labour’s competence to handle the NHS. As we know, the amount of private sector involvement in the NHS is extremely small, and I am not sure that I accept the hon. Lady’s description of how it has all turned out. This is an example of how careful we must all be in dealing with such issues. We must not pretend to our publics that we are something we are not and that our opponents are something that they are not.
My hon. Friend the Member for Stafford (Jeremy Lefroy)—he has great experience, given the work he has done with the NHS—spoke about best practice. He wanted the commission, but again added more pressure in the things it would be doing and considering. I would make the point that such a commission happens at a point in time. I know that it would be designed to look ahead, but it would inevitably consider the circumstances pertaining at the time. We need a process for discussing the NHS and its funding—where the money is coming from and how it is spent. We need to make the process work, rather than thinking that one push into the grass will do the job. Again, I am not sure that the weight will be borne in that way.
Dr Murrison
Earlier in his remarks my right hon. Friend talked about having a discussion within the confines of the Palace of Westminster. He appears to be moving in that direction again. Does he agree that there is a need for a more iterative process with the public at large? A commission of the sort that the right hon. Member for North Norfolk has proposed might go some way towards that.
Alistair Burt
I think that engagement with all involved is essential. When I am away from Westminster, engaging with patients, the public and staff is fundamental to the visits that I make to the services for which I have responsibility.
There is nothing to stop any of the work that the right hon. Member for North Norfolk is suggesting from starting. It is essential that everybody is fully involved. I do not think that the Government or the Opposition will make any of their decisions on the NHS or its expenditure by excluding anyone.
The hon. Member for Walsall South (Valerie Vaz), in a turbo-charged contribution, also spoke of the importance of getting integration right. She reminded us that Dick Crossman started it all off. I am sure that we have all had election manifestos that have spoken of an integrated transport system and integrating health and social care. Now we just have to make sure it happens. She made the point that no amount of talk or number of recommendations relieves someone of the burden of doing it. At the end of the day, it is doing it that counts. That is the role of the Government, while being appropriately challenged by all others.
I am delighted that my hon. Friend the Member for Faversham and Mid Kent (Helen Whately) spoke of the importance of the workforce, particularly the workforce in social care, who have a very difficult time of it. They have great skills and need to be on a career pathway where they can acquire more. They also need to be valued. Again, my hon. Friend believed that the current mechanisms were better than others for dealing with these difficult problems.
To conclude, I will give my sense of the debate. I found it slightly hard to distinguish what the foundations of the debate were—whether it was about the quantum of funding or how the funding was gathered into the health budget in the first place. The commission is expected to cover a breadth of issues, but I am not certain that it can bear the weight. Decisions need to be made, no matter how the information comes forward.
We do not need a commission to deliver the process or to take the heat out of the debate. We have to be careful about how we speak about these subjects. By and large, what happens upstairs gives the public a good sense of how we deal with witnesses who come in from outside, members of the public and each other. We can do much more of that without the need for a commission. We must remember to handle things carefully.
I am not sure that structural change could be handled through a commission. That is very much a local decision. This is not all about funding; it is about how the funding is used. We have to ensure that we do not get into the trap of measuring everything by what we put in, rather than by output. One of the most telling points was when the right hon. Member for North Norfolk said that in the Commonwealth Fund analysis that gave the NHS such a good rating, the one thing it dropped down on was outcomes—treating people and whether people stayed alive. To most people, that is probably the most important outcome of all. We have to make sure that, for all the other good things that we are doing, such as the work the Secretary of State is doing on transparency and all the efforts we are making to give people more information, we recognise the importance of that.
Dr Philippa Whitford
Just on the Commonwealth Fund analysis, the standard that the UK did badly on was actually healthy life expectancy. That is not the same as an outcome in hospital. We may have successful operations, but we have underlying deprivation and ill health.
Mr Deputy Speaker (Mr Lindsay Hoyle)
I just say to the Minister that I did give him the nod. I have been very generous. When we say that he has “up to 15 minutes”, he is meant to take 15 minutes. As he can see from the clock, he has taken a lot longer.
Alistair Burt
I beg your pardon, Mr Deputy Speaker. I have tried to accommodate interventions but I entirely take your point. I am just about to finish and am grateful for your generosity.
I take the hon. Lady’s point, but in conclusion, the Government take advice from a lot of sources on everything connected with health. If the right hon. Member for North Norfolk wants to do exactly what he suggested, he can do it, and we will listen very carefully to him, as we do to others. However, I am afraid that, at the moment, I cannot see a Government-sponsored commission. If we have more debates such as this one, the public will be better served and the House will have done its job.