The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)
My Lords, first, that was an extremely good, incisive speech from the noble Lord, Lord Hunt. I do not agree with all of it—he would not expect me to do so—but it raised all the right issues.
I join everyone in thanking the noble Viscount, Lord Hanworth, for raising this subject. I do not recognise the picture that he painted of the NHS and I have been involved with it since 2002. For the avoidance of any doubt at all, I put it on the record that Jeremy Hunt, myself and the Conservative Government believe wholeheartedly in a tax-funded comprehensive National Health Service. I do not want there to be any doubt about that and I want it to be on the record. I know that Jeremy Hunt would absolutely refute any thought that he believed in an insurance-based National Health Service.
I want to focus noble Lords’ attention on today’s debate, which is about the Act. Therefore, if noble Lords will forgive me, I will not address the social care settlement and will not give our response to the Public Health Post-2013 report, which was raised by the noble Lord, Lord Rea. We have only just received this report. I think that response will come in due course. I say to my noble friend Lord Colwyn that I will not address in any detail the questions he raised about dentistry.
The noble Baroness, Lady Walmsley, gave a list of all the people who opposed the Act. I hope she will not think me churlish if I remind her that the Liberal Democrats supported the Act at the time. On the impact of the Act, I find myself in almost total agreement with the noble Lord, Lord Lipsey—not total agreement, but almost—because if we look at what drives healthcare and the changes in healthcare in this country, it is not the numerous reorganisations, however big or large they may be. It is in part demography, as the noble Baronesses, Lady Armstrong and Lady Pitkeathley, mentioned. Demography is at the heart of it. We have an ageing population yet we have a healthcare service which is not geared up to serve an ageing population, many of whom have multiple long-term conditions. It is also a question of lifestyles. I was in America for much of August and obesity is a massive problem there. It is a huge problem in this country as well. The comments made about Michael Marmot and the social determinants of healthcare were equally true. Poverty is a huge contributor to health inequalities, as we know.
The noble Lord, Lord Kakkar, raised technology and its uptake. Technology will have a huge impact on how we deliver healthcare over the next five, 10 and 20 years. Genomics, bioelectronics, integrated health records, big data and personalised medicine will have a huge impact. We will publish the accelerated access review later in September, which I think will address some of the questions that the noble Lord raised.
The noble Lord, Lord Hunt, raised the much wider issue about life sciences in the post-Brexit world. We cannot address those issues today but it is an absolutely critical area that we as a country have to address.
My noble friend Lord Lansley was absolutely right that money is critical in this regard. When the Act came in, he did not know then as Secretary of State that we were looking at a 10-year period with an approximate 1% real growth in healthcare spending against a background when we were spending 4% or 5% a year for many years, and, of course, a very tight local authority financial settlement as well. Finally, there is an issue of culture. People always say culture eats strategy before breakfast. Well, it devours reorganisations. In a people-centred organisation like the NHS, where you have deep vocational and professional attitudes, culture is hugely powerful. We may think that we can tinker with the healthcare system in this House or in the other House, but getting behavioural change from clinicians takes many years. Let us look at NPfIT, the national programme for information technology, which the noble Lord, Lord Hunt, was very much involved with. You can fiddle around with these things in Richmond House, but to persuade people to change the way they work is much more difficult. I think Sir Muir Gray and the noble Lord, Lord Lipsey, are by and large right: we exaggerate the impact these reorganisations can have.
Let us look at the current performance. I acknowledge it is really tough. The targets for acute hospitals—the four-hour waiting times, the 18-week RTT—and the ambulance service are very hard to meet. I totally acknowledge that. It is not surprising, because over the last five years, the number of attendances in A&E have gone up by 2.4 million people. Over the same period, 1.7 million extra people with suspected cancer have been seen; 6 million more diagnostic tests are taking place this year than five years ago; and there are 22,000 more daily out-patient appointments. I could go on. The growth in demand over this period, at a time of great financial stringency, makes things extremely difficult. We should be under no illusion about it. The NHS is doing magnificently against this difficult background; the noble Lord, Lord Lipsey, gave a personal example. The Economist Intelligence Unit recently found that, in its view, our end-of-life care was the best in the world. The Commonwealth rankings are still very favourable. The OECD has reported on improving outcomes in a number of cancer specialties. However, the noble Lord, Lord Hunt, is right; we have fewer doctors per capita in this country, fewer nurses, fewer MRI machines, and fewer CT machines. Despite all the PFI investment over the years, many hospitals are in desperate need of refurbishment, renovation and rebuilding. The NHS performs fantastically well in very difficult circumstances. I still believe that it is the best-value healthcare service in the world. All this has been helped a great deal by the overhead savings that came out of the Act introduced by the noble Lord, Lord Lansley: £6.9 billion of overhead reduction in the last Parliament, at a one-off reorganisation cost of £1.3 billion. I accept that is a huge amount of money, but nevertheless the overhead savings have been significant.
At the heart of many reorganisations is the issue of how we drive improvement. During the new Labour years, we went through a period of command and control from the centre, moved to targets and then moved to more devolution with foundation trusts. Competition and choice were put at the heart of the new Labour efforts to get sustainable change in the NHS. The Act went no further than that. In many ways it put things on a more even footing. Talking to my noble friend Lord Lansley, it is clear that he is agnostic. I think we are all agnostic about who supplies. The noble Baroness, Lady Walmsley, is agnostic; the noble Lord, Lord Hunt, is agnostic. We want the best suppliers to the NHS, whether they are from the public, private or third sector, or anywhere else. I clearly remember the then Secretary of State for Health, John Reid, now the noble Lord, Lord Reid, talking in 2007 or 2008 about perhaps 15% of supply for elective surgery coming from the private sector. Today, the scale of private provision is 7%.
This is where we come back to culture being stronger than anything that we, or the previous Labour Government, do in these Houses. The culture in the NHS is not all that open to private provision, but where private sector companies can provide a better service at a better price, they should be entitled to do so. However, we have to recognise that the opening up of the market, with choice and competition, has not had the success that we would have hoped for. Healthcare is not a perfect market; it is about as imperfect a market as you can find. So we have moved beyond choice and competition to a new approach—one based on transparency and on trying to identify and eliminate unwarranted variation, whether through the Right Care programme in NHS England or the Getting It Right First Time programme in NHS Improvement. I have huge hopes that we will be able to engage clinicians and try to drive improvement through a process of transparency.
Turning to the future, I want to give noble Lords two short quotations. The first is from the NHS Plan of 2000:
“The NHS is a 1940s system operating in a 21st century world”.
I think we would all agree with that. There is a similar quotation from 2014—14 years later—from Simon Stevens in the NHS Five Year Forward View. He says that there is,
“broad consensus on what that future needs to be … It is a future that dissolves the classic divide, set almost in stone since 1948, between family doctors and hospitals, between physical and mental health, between health and social care, between prevention and treatment. One that no longer sees expertise locked into often out-dated buildings, with services fragmented, patients having to visit multiple professionals … endlessly repeating their details because they use separate paper records. One organised to support people with multiple health conditions, not just single diseases. A future that sees far more care delivered locally but with some services in specialist centres where that clearly produces better results”.
We are all agreed on what the future should be. The noble Baroness, Lady Pitkeathley, says that she has heard this for 15 or 20 years. That is true, but it does not make it wrong. We have to join up health and social care; we have to integrate healthcare. Yet, since 2000—the date of the first quotation I gave—we have gone in almost the opposite direction. We have driven more and more care into acute hospitals.
I shall give your Lordships an interesting statistic. Between 2000 and 2014, the number of hospital consultants rose by 82%, the number of GPs by 22% and the number of community nurses by 14%. That shows where the money has gone—it has, I am afraid, gone to the wrong place. We have to reverse that trend but it is very difficult to do so. We have to take resource away from where it has been going for the last 15, 20 or 40 years and put it back into the community, back into mental health and back into primary care. That is the genesis and essence of the five-year forward view. It is the essence of the devolution to Manchester and it is behind the STPs that we have been talking about.
In response to the question, “Does the 2012 Act hinder or facilitate this process?”, I have to say that I do not think we would have had the five-year forward view without the Act. If that forward view had not been an NHS forward view—if it had involved Tony Blair and Alan Milburn or Jeremy Hunt and David Cameron—it would not have happened. The devolution of a great deal of operational power—away from politicians and away from the Department of Health and Richmond House to the NHS—at least gives us a chance of integrating care in the way that we all know it should happen. Whether we are going to be able to do it, I do not know. We have heard a lot of pessimism today about the STP process. However, I am much more optimistic. I shall not stand here and say that I think we are going to have 44 STPs and that they are absolutely marvellous, but most of these plans are genuinely local. They are being drawn up by local people—by hospital trusts, but also by CCGs and local authorities—many of them are led by local authorities.
I think the jury is out. These plans will come out at the end of October; we will have a chance then to see them. They will not all be good, but if a number of them are good and we can get behind them, it will make a difference. In Simon Stevens’s document, there are a number of care models, which are nearly all based on reducing demand on acute hospitals. It may be that finally we have won the argument. I hope that this will not embarrass the noble Baroness, Lady Armstrong, but three or four months ago Paul Corrigan wrote a very good blog—he is always incisive, and it was a very incisive blog—in which he said that the pressures on acute hospitals are great, and that if we carry on putting resources into acute hospitals, they will not change; there will be no need to change.
For the first time, there is a real possibility that we will get this change, although I do not for one minute underestimate the practical difficulties of doing so. I think it was Mao Tse-Tung who said, when asked about the impact of the French Revolution, that it was too early to say. It probably is too early to give a final verdict on the impact of the Act brought in by my noble friend Lord Lansley. However, like all reorganisations, it will be smaller than originally anticipated. If it enables the fulfilment and the implementation of the five-year forward view, I think it will be judged a resounding success.