The Long-term Sustainability of the NHS and Adult Social Care
Lord Patel
That this House takes note of the Report from the Select Committee on the Long-term Sustainability of the NHS, The Long-term Sustainability of the NHS and Adult Social Care (Session 2016-17, HL Paper 151).
Lord Patel (CB)
My Lords, it is a privilege to open this debate on the long-term sustainability of the NHS and adult social care as the chair of the committee that produced the report. I begin by thanking most sincerely all those who contributed to the report: our specialist advisers, Dr Anita Charlesworth, director of research in economics at the Health Foundation, and Emma Norris, programme director at the Institute for Government; our committee staff, the clerk Patrick Milner, the policy analysts Emily Greenwood and Beth Hooper, and the committee assistants Thomas Cheminais and Vivienne Roach; and, of course, all the committee members, with their collective and individual wisdom and experience—a most agreeable and amiable group that it was my pleasure to work with. I think sometimes small lies are permitted.
Any difficulties that we had in our discussions were smoothed over with spiritual guidance from our resident Prelate, the right reverend Prelate the Bishop of Carlisle. We were sorry to miss the noble Lord, Lord Mawhinney, from most of our inquiry because of his illness, and I wish him well. The noble Lord, Lord Lipsey, is not happy that he will not be here today, but he is recovering from his illness. I wish him well and hope that he is back here soon. In the context of the debate, I am pleased to see the noble Lord, Lord Lansley, in his place. I wish him, too, a full recovery from his illness. We might have another time to discuss his reforms.
Now to the report. The inquiry started in July 2016 and lasted until December 2016—too short for us to cover all the issues in health and social care. Hence our call for evidence was targeted at the key challenges of the long-term sustainability of health and social care. We received more than 193 written submissions, amounting to 500,000 words. We took oral evidence from more than 100 key witnesses. We also received correspondence from more than 3,000 members of the public and hundreds of emails with personal experiences and heartfelt stories. I thank them all for writing to us. We also learned lessons as to how we might be able to engage with the public in future.
We published our report, which was 100 pages long plus annexes, with 34 key non-political recommendations, on 5 April 2017. The report was well received, with favourable comments from a wide spectrum of media—radio, local and national television and later professional journals and blogs—and equally positive comments from think tanks. The Institute for Government has recently expressed an interest in taking forward one of our key recommendations, and is exploring the possibilities related to establishing an independent body—possibly an OBR-style body—for health and social care.
I also thank the chair of the House of Commons Health Select Committee, Dr Sarah Wollaston, who took evidence from me and four other committee members in a full session lasting over three hours, and also—in different sessions—questioned the Secretary of State and the Prime Minister on aspects of our report. All this gave the committee the feeling that we had done a reasonable job on the task given to us.
The long-awaited government response came in late February 2018. It is 39 pages long, and detailed and informative on current initiatives and developments, but a little short on addressing the report’s key recommendations. That is possibly because our important recommendations require a policy rethink and the Government need more time to consider them fully. Their subsequent response will—hopefully—be in actions. I am naturally kind and optimistic and I look forward to that.
This is an important year for the NHS. On 5 July 2018 it will be 70 years since its inception. Lots of celebrations are planned: services in Westminster Abbey and York Minster, features at the Chelsea flower show, celebrations at Wimbledon and much more. I have no doubt that many reviews will be carried out and published by various think tanks around the 70th birthday. As we rightly celebrate, however, concerns continue to be raised about the long-term sustainability of the NHS: its ability to deliver quality care in the face of rising costs, the ageing population and increasing comorbidities, and its ability to cope with developments in expensive medicines and technology, in particular in diagnostic and other areas, with its crumbling infrastructure. For the first time, 52% of the population think that the NHS is the biggest issue facing Britain today. Public confidence in the NHS, in social care and in primary care, is falling.
The weaknesses in the delivery structures of health and social care are made worse by winter pressures on services, as evidenced by daily headlines of bed blocking, queues at A&E, patients on trolleys in hospital corridors, cancellation of elective surgeries for months, and commissioning groups constantly rationing care.
Despite all this, the service, through its dedicated and hard-working workforce, tries to cope and to minimise hardship, and of course there are good initiatives and developments in the pipeline that will improve the service. What is needed, however, is a long-term fix.
A real celebration would be a political consensus, possibly delivered through an all-party commission—which has been asked for by many people, including politicians, political commentators and the media. Even our own Lord Speaker, in an article he wrote more than two years ago, asked for a commission to be established. The Government should initiate such a consensus. The Prime Minister’s legacy would then be the delivery not just of Brexit but, importantly, sustainable health and social care.
I now come to the report itself. It has seven chapters, ending with proposals for building a lasting political consensus. The inquiry found a lack of long-term planning. We were unkind enough to suggest a culture of short-termism. Everyone, it seems, is so absorbed in struggling with day-to-day troubles and with the uncertainty of year-on-year funding settlements that a culture of “here and now” has developed. Our comments, which were not designed to cause upset or to name and shame, should be taken as constructive.
We found that the five-year forward view of the chief executive of NHS England, Simon Stevens, was the only example of strategic planning for the longer term. By the way, if I might digress, in Simon Stevens we have somebody who has, in my view, been given the freedom and authority to be the change needed to build a healthcare system based on outcomes. I am glad that the Secretary of State asked in a recent statement for a five-year or even a 10-year forward financial settlement for the health service. This was one of our key recommendations.
The evidence we received pointed strongly to the fact that, at the heart of securing a long-term future for health is the need for radical service transformation: a change that involves a model of primary care moving away from the small business model to one of bigger group practices, properly resourced and able to deliver on diagnostics. GPs should have the power and authority to shape the delivery of primary and community care, linking with and, at times, being part of secondary care and even involved in hospital care—a model away from the overburdened, bureaucracy-driven current model that we heard about. The model should be attractive for young doctors to flourish in, which would make recruitment to primary care—as it was before—a problem of the past. Equally, it should be a transformation that involves reshaping secondary care, with specialist services consolidated.
Reform is also needed to reduce the bureaucracy and regulatory burdens that play little part in delivering better health outcomes. The current statutory framework frustrates this agenda, but change is needed. With the current focus on integrated, place-based commissioning, the need for two separate bodies, NHS England and NHS Improvement, has to be questioned.
Appropriate funding of the NHS remains the key issue. Years of cuts have led to the decline of services, demoralised the workforce and caused a crumbling infrastructure that in some cases needs the services of a bulldozer. No doubt we will hear of the extra funds given in the last Budget, and prior to that, but significant deficits in the majority of trusts continue. A settled funding plan, with a year-on-year increase linked to the rise in GDP, is our modest recommendation. A possible increase in funding to mark 70 years of the NHS was suggested by the Prime Minister, who mentioned it in her evidence to the House of Commons Liaison Committee. If true, this has to be welcomed: how much and what it will be used for will be the important question. We received clear evidence for maintaining a service free at the point of need.
The lack of any long-term planning for the workforce is the biggest internal threat to the sustainability of the NHS and adult social care. Much of the workforce planning is fragmented. Too much training of our clinical workforce is done through the old model, lacking flexibility and with poor opportunities to update skills. Lack of leadership leads all and sundry to believe that they are in charge of workforce planning and training. It is rather like a bus with too many conductors but no driver. We recommended a strong, independent, well-resourced role for Health Education England to plan for the long term and be accountable. Clear leadership is needed. I gather that our perceived criticism has been taken to heart and that change is on its way. All I can say is: good, and congratulations—may the force be with you.
Prevention of ill health was a key component of Simon Stevens’s five-year forward view, but it has received little attention. There seems to be apathy, centrally driven, around planning for a co-ordinated prevention strategy. A service centred on illness is not sustainable. Much of cardiovascular disease, stroke, cancer—40% of cancers—diabetes, mental health, lung diseases and possibly even dementia has a preventative aspect. We need to learn from models in other countries. I am sure that if the noble Lord, Lord McColl of Dulwich, had been here, he would have had much to say about our obesity epidemic. He has another arrangement in Hong Kong so cannot be here today.
The report also identifies the NHS as a poor adopter of innovations, unable to drive increased productivity, cut waste, use data effectively, reduce variations in care and, above all, reduce variations in outcomes related to inequality and deprivation. The difference in the life expectancy of people in Hackney and the West End of London is the same as that between those in England and Guatemala—about eight years.
Let me now come briefly to social care. Despite extra funding, pressures on social care and the NHS continue. Analysis conducted by the Health Foundation, the Nuffield Trust and the King’s Fund suggests a shortfall of £3.5 billion in social care by 2020. Our report makes a plea for a long-term settlement for social care. As the Government develop their Green Paper on social care for older people, I hope that they will look at all alternatives, apart from the cap, including models of funding that operate in Japan and Germany through a system of hypothecated social insurance, with a defined contribution based on age and income, paid for by all throughout life, with a small top-up contribution made by those who need it—a system that reinforces the principles of social justice, equality and social solidarity to which everyone contributes. Those principles are the bedrock of our much-loved NHS. This is not an ideological suggestion; it is a suggestion based on the one-nation principle.
Let me now turn to accountability. There is a clear need for parliamentary accountability based on transparent information. To this end, following much discussion and an in-depth audit of 16 independent and semi-independent bodies carried out by Emma Norris, programme director at the Institute for Government, we tested an idea with many witnesses and received broad support. We made three recommendations to establish an office for health and care sustainability with a clear and defined remit. The Government responded to this recommendation in 80 words and referred to two websites. The right reverend Prelate the Bishop of Carlisle may well take this further. It is an important recommendation, deserving greater debate and attention, and I hope we will have the opportunity for that at some time.
We are often told that our NHS is the best in the world. Why? Because the Commonwealth Fund, which is based in Massachusetts, places our NHS at number one. The fact is that the fund has its own agenda and uses a methodology to back it. Inconveniently, it also puts the NHS at number 10 for outcomes—and outcomes are what matter to patients. That is what they look for. On the other hand, the Legatum Institute, a London-based think tank, places the NHS 20th, Bloomberg places it 21st and the WHO places it 16th in the world. We need a service based on outcomes. Our outcomes in cardiovascular disease, stroke, cancers and lung diseases are not good compared with those of other, richer countries. A service that is considered accessible and low cost but is poor on outcomes is like having a coffee machine that is cheaper to buy but cannot make coffee.
Time has come for a political consensus to make our much-loved NHS a service that delivers the best care for all, is cost-effective and becomes the model of the best care in the world. We have been there before and we can be again. It is doable, as long as the NHS does not continue to be a political football for those who hope to win votes. I hope that this debate is the start of that political consensus. I beg to move.
Lord Hunt of Kings Heath (Lab)
My Lords, I applaud the noble Lord, Lord Patel, and his committee for this excellent report. It is a huge wake-up call to all concerned about the state of the NHS and social care, which has been given added weight by this morning’s call by the noble Lords, Lord Darzi and Lord Prior, for substantial and long-term increases in funding.
The drivers of change—from demographic factors and changing disease patterns, to technological and medical advances and increasing healthcare costs—are intensifying at a relentless pace. The system, which was originally designed to treat short-term episodes of ill health, is now caring for a patient population with more long-term conditions, more co-morbidities and increasingly complex needs. With the share of the population aged 85 years and above set to increase from 2.4% now to 7.1% in 2066, this represents a formidable challenge for the NHS and social care. That is what makes funding so critical.
On average, spend on the NHS has risen by 3.7% in real terms since 1949-50. Yet at a time when pressures have never been so great, the Government and their coalition predecessor chose to cut adult social care and their spending on the NHS down to a miserable 0.2% per year average in real terms for the whole of the current decade. No wonder the NHS is reeling: targets have been abandoned; waiting times are growing; crude rationing is on the increase; doctors, nurses and other staff are demoralised; and there is huge unmet need in social care.
The Government’s response, to which the noble Lord, Lord Patel, referred, has been what I shall describe as underwhelming. What is remarkable is how many months it took the department to come up with its response. However, it has emerged that the Secretary of State is canvassing support for a long-term funding settlement, potentially embracing a ring-fenced hypothecated tax. This is something the Select Committee gave attention to. I particularly look forward to the comments from the noble Lord, Lord Layard, on this because he has done a lot of work in this area. I can see the attraction. It would enable the public to see a direct link between taxes paid and benefits received in the shape of the NHS.
National insurance is often favoured as the most straightforward way of doing that. English health expenditure in 2015-16, at £119 billion, is remarkably close to NI contributions for the same year, at £114 billion. However, to get to a baseline health and social care figure for England you would have to add another £15 billion for social care. You would then need to add in more to get the kind of settlement that the noble Lords, Lord Patel and Lord Prior, are arguing for, and that would cover only England because the devolved nations, in one way or another, would also have to be factored in. A rise of 1% in national insurance would raise about £5 billion, so to get a reasonable baseline figure national insurance would have to rise considerably. It would also be a huge figure for any Chancellor to effectively lose control of in all the schemes that are being proposed. I am not an expert on national insurance—
Lord Forsyth of Drumlean (Con)
Could the noble Lord indicate whether, when he talks about revenue from a rise in national insurance, he is talking about contributions from employees, or from employees and employers?
Lord Hunt of Kings Heath
It came from a paper from the Office for Budgetary Responsibility. I believe that it is to be a general rise of around 1% across the board, but I will check that out and place a copy of any letter that I send to the noble Lord in the Library.
The point is this: clearly considerations would need to be given if there were to be a rise in national insurance, such as to its impact on employees and employers. Would it be a tax on jobs? Would it be an increase in taxes on working people, when the main beneficiaries of the NHS are older people who do not pay national insurance? Although national insurance contributions are mostly progressive, they become much less so when you hit the upper earnings limit, where employee contributions decrease from 12% to 2% on incomes over £805 per week. I know some noble Lords believe passionately that this is the way forward, and it is an idea worth exploring, but we have to be realistic about some of the drawbacks.
Baroness McIntosh of Pickering (Con)
If 1% were added to national insurance contributions, what would the cost be to the health service, being the largest employer in the land?
Lord Hunt of Kings Heath
I do not know the answer to that but clearly it is another point that has to be factored in, as it would in the care sector more generally. We have already seen this: clearly, it is welcome that the living wage has been introduced, but it has had a knock-on impact when the funding for those services has not gone up at the same time.
I also caution about the desire to create a cross-party approach, as the noble Lord, Lord Patel, asked. Last month, Dr Sarah Wollaston, chair of the Health Select Committee, wrote to the Prime Minister asking for a parliamentary commission on health and care to be established to report on the long-term future funding of the NHS. Today, my noble friend Lord Darzi announced his independent review.
All this is welcome. The more we can debate the pressing need to fund health and social care properly, the more likely it is that the public will support a rise in taxes, which is what I believe this debate is essentially about. But the decision cannot be offshored. In the end, you need a Government with the political will to make the investment necessary, put in place a plan to fix staffing and properly support people to manage their own health care and conditions for the long term. Labour did it. We increased the amount of money going into the health service, reduced waiting times dramatically and invested in the infrastructure. It can be done, but it takes a Government with the political will to do it.
Alongside the issue of funding, we surely have to get on with redesigning the current regulatory and structural mess that the Government have got the NHS into. As the Select Committee report said:
“A culture of short termism seems to prevail in the NHS and … social care”,
with the department,
“unable or unwilling to think beyond the next few years”,
so there is no long-term funding plan and no national long-term strategy on workforce planning. The NHS is seemingly incapable of driving up productivity, using data effectively or adopting new technology quickly, as the Select Committee concluded.
The Health and Social Care Act 2012 has much to answer for. Its conflicting threads have led to fragmentation, friction and confusion. The Act is dominated by obeisance to a competitive market, with economic regulation to the fore. It established lighter touch oversight from the Government, with NHS England created as an arms-length organisation, subject only to an annual mandate, and GPs were supposedly put at the heart of decision-making through their dominance of clinical commissioning groups.
What has been the reality? Competition has proved a very expensive foible. It reached its ultimate folly with the competition authorities intervening in a sensible reconfiguration of service proposals at a cost of millions of pounds. Large parts of the competition regime have now been ditched but, as the Act has not been repealed, NHS bodies are endlessly at risk of legal challenge. As for light-touch oversight, the reality is that NHS England behaves in the way of all state bureaucracies: heavy-handed and highly interventionist. As for GPs being in control, so frustrated have CCG leaders become at their impotence and unwanted role as rationers of services that many have gone back to their surgeries or even retired.
Ministers preside over this with glorious ambiguity, consistently washing their hands of the shambles and performance failures that they and their colleagues created. The Secretary of State humiliatingly calls in the bosses of the so-called independent NHS Improvement, NHS England and CQC for a weekly berating and demand that ever more chief executives be sacked.
When the Sainsbury chief, Roy Griffiths, was asked to look into NHS management in 1983, he said that if Florence Nightingale were to come back to inspect NHS hospitals, she would find no one in charge. I wonder, if that great man were asked to come back to do a report, what he would say about the current arrangement. Actually, I think we have a pretty good idea. The noble Lord, Lord Rose, was asked by the Secretary of State in 2014 to recommend how leadership in NHS trusts could be transformed. By the time he finished, I think the Secretary of State regretted asking the question, because in his report he talked about the level and pace of change being unsustainably high, with the administrative, bureaucratic and regulatory burden fast becoming unstoppable. He talked about a lack of stability and a deep-rooted concern over the many and varied messages sent from the centre of government. Indeed, not surprisingly, the report died the death. We continue with a huge system that is under huge pressure, underfunded, under-resourced with people, and yet it is having to cope with one of the most complex, conflicting administrative systems ever seen.
One thing I particularly welcome in the report of the noble Lord, Lord Patel, is that he did not confine himself just to funding. He talked about the culture and some of the other issues that need to be tackled. The report is excellent, and we have an excellent debate ahead of us. I hope that the Government will listen. It is a great pleasure to follow the noble Lord, Lord Patel, who has shown such leadership in chairing the Select Committee and presenting his report so well this morning.
Lord Willis of Knaresborough (LD)
My Lords, I begin by congratulating the noble Lord, Lord Patel, on his excellent introduction to this debate, his expert chairmanship of the inquiry, and his patience with committee members who sometimes resemble a herd of cats trying to be assembled into some order. Through his persistence in eventually getting a response from the Government, he has shown tremendous tenacity over the past 12 months. I am rather sorry that the spokesman from the Labour Benches immediately rejected the core thread of the report, which is: without consensus, we will go nowhere. Simply talking about the problems we have today, without being able to look ahead to 10 or 15 years, which is exactly what the report does, does a disservice to this House and the whole of the NHS and adult social care.
I am sorry that there was such a non-committal response from the Government, although it is gratifying that a number of the recommendations have already found their way into new policy initiatives. A department for health and social care is welcome, and we should celebrate it. The acceptance of a long-term funding settlement for health and social care is welcome and we should work on it. A return to a Dilnot-esque funding formula for adult social care again is back on the table, and a draft health and social care workforce survey is again extremely welcome. The latter is particularly welcome following an admission by the Secretary of State that,
“workforce planning is an area where we have failed, and successive governments have failed”.
However the strength of this report, with its wealth of oral and written evidence, is its recognition that the health service and adult social care is a very complex organisation. If we are to develop a 21st century system, we need long-term bold political decisions. Frankly, simply raking over the coals of past mistakes will not get us there.
We added “adult social care” to the title of our report as we swiftly recognised the folly of treating NHS and adult social care as separate organisms within a future healthcare ecosystem. Despite the compelling case for substantially more resources to secure long-term sustainability, we did not become preoccupied with quantifying the amount needed. We emphasised that resource must follow function and that a far more pressing priority for sustainability was service transformation. That point was forcefully brought home when we examined the development of the STP programme, where transformation has been largely abandoned on the altar of sustainability simply to achieve budgetary targets.
Service transformation maintained by long-term funding stability must be the holy grail for all of us, but that will not happen if transformation has to meet early and often unrealistic financial targets. This is particularly true of workforce transformation, where often double funding is required as systems overlap and develop. HEE’s recently published draft health and care workforce survey for England goes up to 2027 and commences with quote from the noble Lord, Lord Crisp, from an article in the Lancet in 2010, when he said:
“Health is all about people … the core space of every health care system is occupied by the unique encounter between one set of people who need services and another who have been entrusted to deliver them”.
That has not been the case. All too often, those who deliver services, the workforce, are treated as a commodity rather than as a precious resource. The fact that this is the first time in 25 years that the health service in England has consulted on a comprehensive workforce survey is as damning an indictment of past policy as it is ambitious about the future.
The consultation is in direct response to recommendations 6, 8, 9 and 12 of our report and, in particular, the challenge to Health Education England to take a far bolder lead in co-ordinating workforce planning with other key partners. While I declare an interest as a consultant to HEE, I applaud HEE and its colleagues in NHS England, NHSI, Public Health England, the Care Quality Commission, NICE and the Department of Health and Social Care on coming together for this initiative—the first time that has happened since 2012 and, again, it should be celebrated.
However, transforming the workforce will not be possible without challenging what Gavin Larner, director of workforce at the DoH, said are,
“strong culturally conservative parts of our healthcare system, where the different professional tribes see particular ways of delivering services”.
The committee recognised this challenge, despite the number of past presidents of royal colleges there, and recommendations 11 and 12 are directed at clinical hierarchies. The committee challenged the current length of medical training, the overreliance on traditional disciplines and early career specialisation, the difficulty in moving between disciplines, and the difficulty of the appellation of prior learning, even when postgraduate qualifications at doctoral level were reached in several appropriate subjects.
We challenged why, when 70% of patient episodes are dealt with in primary care, there is such an imbalance of postgraduate specialism in community-based practice. But we also applauded the initiative by HEE, supported by the NMC, to introduce nurse associate roles, recruiting and training some 5,000 additional colleagues this year, 50% of whom want to train as registered nurses. So we are growing our own nurses rather than depending on recruiting from abroad, adding to the skills mix on wards and in the community. Transformation means that many new roles will be introduced in traditional areas from surgery to midwifery, as well as nascent roles yet to emerge. The emphasis of royal colleges and other professional leadership groups as well as government and regulators should be on assessing their benefits to patients, not on fighting a rearguard action to protect past structures.
The future sustainability of the NHS and adult social care is not about more of the same but about developing a workforce that is flexible, ambitious and confident. As the report states, that will require continuous investment in healthcare’s most valuable resource, its people.
Lord Kakkar (CB)
My Lords, I join in congratulating my noble friend Lord Patel on the extraordinary way in which he chaired the committee; I had the privilege of being one of its members. I also thank him for the remarkable leadership that he has provided in your Lordships’ House when matters of health are debated, and to me personally—he was a supporter when I was introduced to your Lordships’ House some eight years ago. He has been my mentor and has helped me understand how best to contribute to the work of this House.
I declare my interests as professor of surgery at University College London and chairman of University College London Partners. It is also a privilege to follow the noble Lord, Lord Willis of Knaresborough. He made the very important point that the NHS is about people—the people the NHS has the privilege to serve and those who ensure that the service can be delivered through their commitment and sacrifice.
As we move towards the 70th-year celebration of the NHS, it is very important for us to understand the contribution of those who have served in the NHS and have come from abroad to do so, particularly those from many Commonwealth nations. Their contribution has ensured that we are in a position today to have this debate to talk about the future sustainability of the NHS. Without those countless tens of thousands of contributions, frequently unrecognised, we would not have been in a position to establish a service that has had such a profound impact, not only on the health of our nation but on social cohesion. Will the Minister ensure that all those contributions, including of those who have come from overseas to serve our NHS, are properly recognised as part of the celebrations?
That is also an important point in understanding why the service is at times seen as demoralised. People need to be motivated. Regrettably, the NHS has become an organisation frequently defined by regulation and targets rather than by a commitment to a professional vocation—which was definitely a founding element of the NHS in 1948. Some way needs to be found to reinvigorate that professional vocational commitment so that it once again represents a foundation for the way care is delivered, while of course recognising that standards have to be met and quality must be at the heart of delivery of the National Health Service.
As we have heard, the committee considered the fundamental question of the long-term sustainability of health and care. In that regard, a need to develop consensus in three important areas was identified: on how a future NHS should be funded, on how a future NHS and care system should be delivered, and on what should be delivered as part of the nationally agreed consensus on health and care. It is vital for government and other leaders—political, professional and, more generally, public—to determine how a consensus is to be achieved among those different constituencies and between them to ensure that a sustainable model can be adopted for the future.
On the first question, of a consensus around funding, the reality is that most public debate and discourse about the NHS and broader delivery of care focuses on funding. That is a principal topic of debate. The issues have been well described: how will we understand the impact of changing demographics on the need for the delivery of both healthcare and social care? How do we model the impact of changes brought about by the adoption of new working practices and technology as they offset the increased demands created by such change in demographic? How will that balance be understood and modelled over time? How will we create a political consensus that ensures that a funding strategy is secured and available over a prolonged period well beyond the life of a single Parliament and, potentially, a single Government?
A second area where consensus is needed is on how care is delivered. There is no question that the delivery of primary care, secondary hospital-based care and specialist care requires radical transformation to ensure the adoption of innovation and technology that will improve clinical outcomes—which, as we have heard from my noble friend, Lord Patel, patients rate above almost anything else. How will we achieve a consensus on the reform of primary care? How will we achieve a consensus in driving a strategy for true integrated care that understands the lifetime needs and broad chronic disease needs of individual patients, rather than looking specifically at institution-based care, be it in hospital or out of it? How will we achieve consensus on transforming the principal focus of the NHS from being on illness to being on preventing ill health so that it becomes fundamentally sustainable in the decades to come? These are complicated questions. Although we have seen since the royal commission of 1975 many subsequent commissions, reports, reviews and reorganisations, all well-meaning and making small steps towards longer-term sustainability for the NHS, none to date has delivered what was needed or ultimately expected to secure the fundamental base that will give us a sustainable NHS.
Thirdly, there is the very sensitive issue of what the NHS and social care should deliver. This has become an increasingly difficult political question. Frequently, decisions on what should be provided are taken on an ad hoc basis, with different decision-making in different parts of the country. Frequently, that is seen as unfair and unjust in a system designed principally as a national service there at the point of delivery for all our fellow citizens, with every citizen able to be confident that they will receive just as good care and access to innovation and to the potential to a clinical outcome, wherever they live and whatever their background.
Such challenges are not new to this Parliament. I had a very interesting conversation with the right honourable Member for Birkenhead in the other place, who brought to my attention a period in the 1830s with a similar national institution. On that occasion, the Church faced very serious problems, and a royal commission was established by Grey in 1832 to address the question of the Church and how it disposed of its funding, and the changing needs and demographics of the British people. In 1835, the Ecclesiastical Revenues Commission was established by Peel and, on that occasion, a commission with a slightly different remit, which had the ability to inquire and identify problems and suggest solutions but also to act and implement with the supervision of Parliament. I do not suggest that that is the solution at the moment, but it must be for Her Majesty’s Government to identify a way at this important time—with these important challenges and on the basis of this detailed report—to find a method to achieve a consensus and move forward the national debate, addressing what is now becoming a critical problem.
The Lord Bishop of Carlisle
My Lords, like other noble Lords who have already spoken and who will speak in this debate, I had the great privilege of serving on the Select Committee that produced the report of which we are, I hope, taking note today. Like them, I pay tribute to my colleagues, from whom I learned a great deal, and to our excellent chairman, the noble Lord, Lord Patel.
Since the report was published, more than a year ago, I found myself presenting its findings in various venues in Cumbria, where I live and work. On some occasions, local Members of Parliament and senior NHS staff have also been involved, but on every occasion the interest generated has been huge, which is a reminder, should we need it, of the importance of this topic to every citizen in every part of this country. At the same time, I have tried to emphasise again and again the underlying theme, the recurring refrain of the whole report—the serious lack of long-term vision and planning for the NHS, especially with regard to issues such as funding and workforce transformation, both of which have already been mentioned. Simon Stevens’s five-year forward view is extremely encouraging and greatly to be welcomed, and I echo the positive comments made about it by the noble Lord, Lord Patel, in his introduction to this debate. But we need to look 15 or even 20 years ahead and, at present, that is simply not happening.
In attempting to summarise our 34 recommendations, the one that has consistently for me come out on top is number 33, which calls for the establishing of an office for health and care sustainability, rather like the Office for Budget Responsibility or the National Infrastructure Commission. The need for such a body was highlighted for us by the president of the Royal College of Physicians, Dr Jane Dacre, in her evidence to the committee. She said:
“We are blighted by short-term planning that goes along with the electoral cycle. The health service is a very big and very expensive organisation that does fantastically well. But it is frequently the victim of short-term political decisions that make it less efficient”.
We clearly need a co-ordinated, cross-governmental approach that requires an independent mechanism to scrutinise longer-term issues.
What would this look like? The audit of independent and semi-independent public bodies, in appendix 5 of our report, provides a basis for determining the remit for just such an office for health and care sustainability. We have suggested that it should focus on three key issues in particular: first, monitoring changing demographic trends, as mentioned by the noble Lord, Lord Kakkar, disease profiles and future service demand; secondly, thinking about the implications of future change for the NHS workforce and the skills mix; and, thirdly, looking at the stability and alignment of health and social care funding allocations relative to future demand, which, as we all know and as the noble Lords, Lord Patel and Lord Hunt of Kings Heath, have pointed out, is likely to grow hugely in the years to come. It should constantly look up to 20 years ahead and should play no part in the day-to-day operation of the NHS. It should report directly to Parliament, which I think addresses the cross-party hesitations expressed by the noble Lord, Lord Hunt. In fact, the value of such a body, which would not need to be very large, is blindingly obvious. That is why the Government’s response to this recommendation is so deeply disappointing. They say:
“We believe that the functions of the proposed body would replicate existing mechanisms”,
but existing mechanisms are not currently prompting or helping anyone to plan for the long-term sustainability of the NHS and adult social care. This dismissal of our fundamental recommendation is both perfunctory and inadequate.
As we have already been reminded, on 23 March this year the chair of the House of Commons Health and Social Care Committee, together with the chairs of several other parliamentary Select Committees, requested the Prime Minister to establish a parliamentary commission on health and social care across both Houses. I warmly support that request, I look forward to its approval and I hope very much that the commission’s proposals will firmly include establishing an office for health and care sustainability.
Lord Prior of Brampton (Con)
My Lords, I first declare my interest as chairman of UCLH. The Select Committee has produced an outstanding report and I pay tribute to the noble Lord, Lord Patel—I was going to say my noble friend. He is a mentor to not only the noble Lord, Lord Kakkar; I regard him as a mentor to me as well in this place.
I make the obvious point: after 70 years, the NHS is still a remarkable institution. I do not think anyone in this House today is going to say that the NHS should be disbanded or that it is no longer fit for purpose. That is pretty remarkable after 70 years; there are very few organisations that have weathered so well. If you look around the world at other social insurance-funded systems or private insurance-funded systems, there is no doubt that the NHS—which pools the risks, whether genetic or social, of a whole nation—can deliver both fair and efficient healthcare. When Theresa May became Prime Minister she talked about social justice, and no institution better embodies those words than the National Health Service.
I will make four points, the first of which is on money. If we look back over the life of the NHS, there is a correlation between the amount of money that goes in and the productivity that comes out. It goes in fits and starts. One Government come in and put too much money in, and productivity goes down. The last Labour Government, whom the noble Lord, Lord Hunt, referred to, got the NHS to make huge progress, but during much of that time in the early 2000s a lot of waste and inefficiency went along with that extra money going into the system. We need a long-term settlement so that people in the NHS can plan for the future. It is not hard to create a long-term settlement, because the spending on the NHS is so determined by demography and technology that it is quite easy to predict. As some noble Lords will know, the IPPR has made a prediction of £50 billion extra by 2030. Whether it is £50 billion or £40 billion, surely that figure can be agreed on. If we are to have a cross-party view on this, exactly where we could have one is on what those requirements are for the NHS. However that is financed—whether through some form of hypothecation from general taxation, charging or productivity increases—that seems a perfectly legitimate area for proper political debate.
Secondly, on reform, by fragmenting the commissioning system into 212 clinical commissioning groups the Health and Social Care Act—my noble friend Lord Lansley, who was here a minute ago, was the architect of that—has made the process of integration more difficult. It also did not address the foundation trust issue, which was of course set up by the Labour Party when it was in government, and which has made integration much more difficult. If you are a foundation trust, you are solely interested in your own financial results and performance, and not in the performance of the system for the population as a whole which you service. We therefore not only have to address the consolidation of CCGs but have to look again at the regulation of foundation trusts. There is now evidence that where acute care and primary care work together in integrated systems, we reduce the number of emergency admissions into hospitals so that people are treated outside acute hospitals, which is all to the good.
The second area where the Health and Social Care Act was not helpful was in the split roles between NHS Improvement and NHS England, which has led to a fairly high degree of frustration and split responsibilities. To bring those two organisations together could well be part of the future. However, there is one caveat. Here I pay tribute to the noble Lord, Lord Carter of Coles, his team at NHS Improvement and their work on the Model Hospital and on the Getting It Right First Time initiative, led by Professor Briggs and Professor Evans. That “improvement” part of NHS Improvement should not be part of the regulator. You cannot be both a regulator with a big stick and a genuine improvement agency. However, the work the noble Lord has done in NHS Improvement should not be lost; it should be taken out of a combined NHS Improvement and NHS England organisation and treated separately.
The last part of any reform programme must be to emphasise prevention, as the noble Lord, Lord Patel, has already mentioned. We cannot regard the NHS purely as an organisation which cures the sick; it has to prevent people being sick in the first place. That has not received enough emphasis over the last six years.
I would like the Minister to address two other points in winding up. The first is that there should be a greater obligation on the NHS to support the life sciences industry in the UK. At the moment, it seeks to meet its own budgets and deliver care at the lowest possible cost but, for the economy and the country as a whole, the life sciences industry is absolutely essential. When it comes to developing cell and gene therapies and encouraging the convergence of data science and medical science in this country, for example, the NHS ought to have a greater obligation to support those initiatives and to become a test bed for British technology and science. However, the work that the NIHR has done under the leadership of Sally Davies and Chris Whitty in driving translational research in this country over the last five years has been terrific.
I should like to end on a point about Brexit. The Minister will know that my views and his on Brexit are very different but, whatever the outcome of the negotiations, there are three aspects of it which he may be able to give me some assurance on today: first, that we will remain part of any EU research programme such as Horizon 2020; secondly, that we will have a visa programme, not just for doctors and nurses but for the brightest and the best researchers, that is flexible and allows us to attract the best in the world to this country; and, finally, that we will remain part of the regulatory system in the European Union for medicines. If we do not, the chances of this country manufacturing these new advanced cell and gene therapies will disappear. We lost monoclonal antibodies from this country 10 or 15 years ago; we must be able to manufacture cell and gene therapies in this country. If we have to go through enormous compliance issues with customs at the borders, we will not be able to do so. I hope that we can have an assurance on that point.
Lord Turnberg (Lab)
My Lords, it was my pleasure too to sit on the Select Committee under the extremely wise chairmanship of the noble Lord, Lord Patel, and I congratulate him on introducing the debate today so well. Perhaps I may say how pleased I am to follow the noble Lord, Lord Prior. What he said very much resonated with me, as did what was said by the right reverend Prelate the Bishop of Carlisle.
Having heard from a huge number of witnesses, the committee came up with a very sensible and practical set of recommendations for the long term, but it was less than encouraging to have, after an extremely long gestation, the Government’s rather anodyne response. Therefore, it was somewhat surprising to hear the Secretary of State on Robert Peston’s programme a few Sundays ago saying some of the things that we had advocated. He spoke of the need for a 10-year plan and a ring-fenced funding system—a hypothecated tax, in other words—for health. I just hope that he was not so far off-piste that he will be given the boot. He had already persuaded the Prime Minister that he should be responsible for community services as well as health, if not for the funding of it. I never thought I would ever say this, but I just hope that he keeps his job.
I want to focus on just two aspects: integrated care and a hypothecated tax system. It seems trite now to say that any long-term solution to the problems of the NHS has to include care in the community. Draconian cuts have meant that social services are no longer coping with the increasing load of the elderly and infirm—everyone says that. The whole system is clogged up and we have been talking for ever, it seems, about integrating health and social care in a seamless system.
It is not as though we do not have models of how that can be achieved. The one that I know best and the one that seems to be working most successfully is that run by Sir David Dalton in Salford. I take some pride in that because I spent most of my clinical working life at Salford Royal Hospital, although I am well aware that it has taken considerable advantage of my having left and has done great things. As well as running the hospital extremely efficiently with a very enthusiastic team of doctors and nurses—which is somewhat rare in the health service at the moment—David Dalton has now been given the local authority’s total budget for social services and community care. He employs the social workers, community nurses and two salaried general practices, and has now taken over mental health services too. He works very closely with the single CCG for Salford, as well as with the local authority, and he is now able to see the remarkable fruits of a completely seamless service for the 250,000 population of Salford. Dalton was asked to take over three local NHS trusts that were in financial trouble, and he is now busily turning them round very successfully. That shows what can be done if you have the right leadership, and if we can keep such leaders in their posts for the 17 years that it has taken Dalton to get to this point.
Those factors—excellent leadership that is not distracted by constant efforts to reach savings targets and not moving on every couple of years in some reorganisation or another—are both difficult to achieve. A change in culture requires sustained and persistent effort over a long period of time and is never a short-term possibility. Will the Minister consider ways in which the Government can provide the best conditions to allow this to happen, invest in long-term, high-quality leadership and give them the right incentives, and not get involved in any more reorganisations of the NHS? That does not mean that Salford and others do not need more money; they clearly do. We know that all NHS and social services have been starved of funds for so many years, despite the increasing demand. The question is how more money can be found.
I was one of those members of our committee who strongly favoured a hypothecated tax specifically ring-fenced for health and social care. I was bolstered in that belief by two distinguished economists: my noble friend Lord Layard, who will speak later in the debate, and the noble Lord, Lord Macpherson, neither of whom can be considered amateurs. It is noteworthy that the noble Lord, Lord Macpherson, was the Permanent Secretary in the Treasury, where you might expect some resistance to any form of hypothecation. Of course, there are all sorts of objections to hypothecation: it limits the flexibility of the Treasury to respond to the ups and downs of the economy, and, if it is based on national insurance payments, we know that the current sources of NI would not be sufficient by themselves to meet the costs of health and social care. Let me try to deal with each of those objections in turn.
First, national insurance is currently paid only by those below retirement age, who, by and large, use the NHS much less than those over that age and who themselves do not pay. But why not? They pay tax on earned and other income, so why not national insurance? It may not go down terribly well in your Lordships’ House, but national insurance paid by those over retirement age would go some way to evening out the intergenerational tax burden. Incidentally, polls show that it is true that the public at large would be willing to pay more tax, if it was earmarked for healthcare. We have a listening public prepared for hypothecation and—who knows?—perhaps the Treasury too could be persuaded if it recognised that it would not be under political pressure and bothered every year with bids for yet more resources for the NHS.
Secondly, how can we smooth out the impact of fluctuations in the economy and income? My noble friend Lord Layard—who will no doubt tell me if I have got this wrong—suggests that this could be achieved by a five-year agreed figure plus a 10-year estimated figure accepted by the Treasury, which would be able to take in the excess in good years and dole it out in the bad. I was delighted when, in his recent interview, Jeremy Hunt did not rule this out. I hope the Minister will follow this and be just as brave. Can he tell us anything about the Treasury’s reaction to the Secretary of State’s admission? Listening to the Chancellor recently does not give me much encouragement and so I will not be holding my breath, but at least the idea is out in the open. I await the Minister’s response with interest.
Lord Rodgers of Quarry Bank (LD)
My Lords, I welcomed the decision to set up the committee in order to take a mature, carefully considered, all-round view of the NHS, more than simply the need for stable and predictable funding. I share the Government’s response to the report: it is thorough and thoughtful, within the limits of time, and it raises most of the right questions.
I have played no significant part in health matters in the House except on stroke, which I shall mention later. But for many years, as a Member of Parliament, I dealt daily with the health problems of my constituents. In the 1960s my simple campaigning slogan was “Jobs, homes, schools and pensions” Then, in about the mid-1970s, I switched to “Jobs, homes, schools and health”. Since then, the NHS—the national religion, as the committee calls it—has been full of pain as well as pleasure.
It may be pretentious to refer to a book, The Politics of Change, which I wrote 30 years ago but in a chapter entitled “Is Public Expenditure Enough?”, I mentioned needs and means in health. It was not, I said, until 1976 that any attempt was made to establish rational and systematic priorities. Barbara Castle, then Secretary of State for Social Services, said:
“Demand will always outstrip our capacity … Choice is never easy but choose we must”.
That was also broadly the message of the Cabinet Office central policy review committee at that time, as the noble Baroness, Lady Blackstone, may recall.
However, all too often over the years since then, politicians on both sides have ducked priorities and choice and delayed awkward decisions. That was the case with preventive medicine, and Aneurin Bevin himself said that,
“the victories won by preventive medicine are much the most important for mankind”.
When death, disablement, injury and social distress could be avoided, even with a net saving of public expenditure over time, it seems extraordinary that a double bonus was ignored. I strongly support recommendation 30.
When I was Secretary of State for Transport in the late 1970s it was clear that a single, simple step of making seat belts compulsory could save 1,000 lives a year, prevent some permanent disablement and achieve substantial savings within the NHS. However, progress was slow because the Official Opposition and the Back Benches on both sides of the House claimed that seat belts were an unacceptable restriction of personal freedom. When I managed to get my seat belts on the Cabinet agenda, the Prime Minister was clearly half-hearted. Then, when I won in Cabinet, it took six months before I reached my Second Reading in the Commons. In carrying the Bill by 244 votes to 147, it was opposed by the Deputy Leader of the Labour Party and its Government’s Chief Whip.
I welcome the report’s call for more substantial and sustained action to achieve parity of esteem between mental and physical health. I endorse everything in the report about obesity and the failure by successive Governments to lead a robust campaign.
The report mentions stroke. It was in 1993 that the Lancet showed for the first time that stroke units saved lives and reduced disability. However, it took 14 years before the national stroke strategy was published. The Government in response to the report quotes the chief executive of the Stroke Association on what has been achieved by the reconfiguration of stroke services centralised in a fewer number of hospitals. I entirely share this view and applaud the London Hyper Acute Unit. As a victim of stroke, I am able to acknowledge the major strides in dealing with this illness over the past 15 years. The Government must maintain that momentum. It is good news that the new National Medical Director is now working toward a fully worked-out plan and the National Stroke Audit is being recommissioned. I ask the Minister only to say today, or in writing, what has happened to the reorganisation of acute stroke care in Greater Manchester and whether—or when—the changes in acute stroke services will be extended to elsewhere in the country.
Appropriate to a Select Committee, the report is wholly cross-party in tone. Quite apart from the closing paragraphs of the report, I greatly welcome that, but there is much more to be done to reconcile the spirit and purpose of the Bill and the willingness of Members of Parliament, local politicians and activists to accept change. They must work alongside CCGs and other NHS organisations to set priorities and make choices.
Baroness Murphy (CB)
My Lords, the report from the committee of the noble Lord, Lord Patel, is exemplary in its response to the evidence it received and in its sensible recommendations. Sadly, we can almost guarantee that it will not be acted on. The response so far has been underwhelming, as other noble Lords have said. We do not need just a five-year plan or a 10-year one; as others have said, we need a 20-year plan, minimum. We have understood the demographics of our ageing population for 50 years—the trajectory is there before us—but heads have remained in the sand. My question is not how we can sustain the current system but why we would want to, given its sad state. I do not have any neat solutions, although I may echo some of the words of the noble Lord, Lord Turnberg.
I think that the situation is far worse than people believe. I have worked in the NHS all my working life, as a doctor, psychiatrist, academic and a manager; in fact, it was Roy Griffiths who persuaded me to become a manager when he did his report. I am now ashamed when I compare the healthcare here in England with what is available in other European countries. In particular, the primary care system of which we were so proud is now so poor at delivering access to people that, according to the OECD, we are the fourth-worst country for people being unable to access care and ending up in A&E as a result. Only three countries in Europe are worse than us: Slovenia, the Czech Republic and Slovakia. That is how bad access to primary care is here.
Our primary care system no longer provides a 24-hour service. Primary care and hospital systems have become even more fearsomely bureaucratic, strung up by regulation. Morale among doctors and nurses is as bad as I have ever witnessed. Last year, I went to a conference for young psychiatrists in Nottingham and I was shocked by their tales of the way the system impacts on their training experience and the way they are sent around and told what to do. It seemed a total anathema to the way I did my training. Our mental health system remains outrageously, chronically underfunded and the CCG system still allows money to be transferred sideways into other services that shout louder.
We smugly criticise the US for allowing the homicide by guns of 8,000 people every year. We tut about its gun laws. Yet, according to WHO statistics for 2015, we in the UK are five times more likely than Americans to die, once diagnosed, of mesothelioma, nearly three times as likely to die of oesophageal cancer, twice as likely to die of stomach cancer and nearly twice as likely to die of prostate and bladder cancer. Many more thousands of people in the UK die of poor treatment and inadequate follow-up. For example, prevention services would help diabetes not to become a crisis.
Why are we not scandalised by these figures? We should be. It is not that we have worse screening systems, but because our treatment, follow-up and aggressive care of people to provide better outcomes is simply not as good as many American and European systems.
Forty years ago I was really proud to be at the forefront of delivering dementia care services that I honestly believe were the best in the world. Forty years on we have fallen woefully behind. It has been demonstrated by research that it is now easier to get better care if you are impoverished in Texas than if you are a middling well-off person in the United Kingdom.
Yet the NHS is so beloved by the general population that when he was Chancellor, Nigel Lawson—now the noble Lord, Lord Lawson—said that the closest thing the English have to a religion is the NHS. How true that is. Because it is funded directly out of taxation, it is often starved of funds when tax revenues are inadequate or when the Government, as now, have a different approach to what should be funded and what should not. When we get these bursts of funding, as the noble Lord, Lord Prior, said, much of the money goes into increased staff salaries. Productivity, which is already appallingly low, goes down and the incentive is often to do less work rather than more. The investment must go into reshaping the system. We need a long-term settlement and political consensus about how to do it.
We have heard that perhaps one change that would make a huge difference is an integrated care system—by which I mean health and social care working together in clinical teams. We have known for many years that just having a joint budget, as they have in Northern Ireland, does not work adequately. We need proper care management systems working together—as we have heard happens well in Salford—but we really need case management working around clinical teams. That creates the elite feeling that people enjoy working in where they are really producing better outcomes for people. If I had one change to make, it would be to integrate funding and delivery of social and health care across the nation. I do not believe that that would fundamentally undermine the principles of the NHS.
My final point is that we need to look at how people understand where funds come from and where they go to. At the moment they see no relation between what they pay and what they get. It is time to ensure that the general public really understand that they are getting a cheap system that is poorly funded. They could have it so much better if they knew what they were putting into it and could see where it went from their own taxes. So I support hypothecated funding to help people understand where it is going.
Baroness Redfern (Con)
My Lords, I am pleased to take part in this long-awaited debate. I thank the committee’s chairman, the noble Lord, Lord Patel, for his diligence and commitment. It was a privilege to serve as a member of the committee. I also thank the special advisers and clerks of the committee who ably supported us in producing this report.
Our main values may not have changed over the past 70 years, but what has changed, and is to be welcomed, is that we now see an average life expectancy for UK citizens of more than 80 years. To accommodate a growing population with its increasing expectations and demands, we have to have an NHS that is fit for the future. Clearly, just protecting the NHS budget will not address the financial challenges that lie ahead, but to survive it must change its aim to raise performance and deliver a safe, high-quality, as well as good value for money, service.
The overriding consensus throughout was a need for a future settlement far longer than the five-year forward view, rather than intermittent budgets being added on, however welcome. I do not wish to minimise that extra funding; it is welcome.
From witnesses interviewed, there would appear to be a lack of a comprehensive national long-term strategy to secure the appropriately skilled, well-trained and committed workforce that the health and care system will need over the next 10, 15 or 20 years. It is therefore essential that workforce planning is based on predicted need rather than what budget is available at that place and time.
This report highlights the issue of there being a limited workforce strategy with too much reliance on overseas recruitment. With insufficient attention being paid to training the existing workforce, there will be a need for radical reform of many training courses for medical recruits to keep pace with change. Evidence submitted supported a need to be smarter at addressing the changing mix of skills required by a changing patient population. There needs to be attention on education and training to deliver efficiency and greater productivity, with good, clear career progression and opportunities to take on other career roles. We need to increase morale and bring back more enthusiasm.
The future of the health service relies on the NHS having the trained staff it needs to deliver services, in terms of both numbers and the appropriate staff to deliver care in a different way.
As witnesses stated, we must not again face the problem of a stop/go approach if, for example, we are to achieve world-class cancer outcomes. Staff shortages cannot be allowed to have an impact on the delivery of cancer diagnosis and care.
Before I go further it is important to have on record thanks to all the hardworking NHS staff, who perform above and beyond their remit, and to acknowledge the Government’s long-awaited lifting of pay restraint.
Systems, too, have to change, beginning with the need to reduce bureaucracy. Given the amount of paperwork and pressure on the front line from all quarters, there is an urgent need to move to one single dataset to increase productivity, especially because unacceptable variations in patient outcomes are undermining the effectiveness and efficiency of the NHS. The NHS needs to show good performance throughout the UK.
The NHS has the potential to be a world leader in the use of data for research and service improvement but its digital infrastructure needs transforming as a matter of priority. Big data technologies have the potential to improve both NHS services and the research underpinning advances in healthcare.
It is critical for citizens to have confidence, when data is used in the public interest, that strong safeguards provide a firewall. Data-sharing needs to become a priority and not be left to remote national bodies. Evidence has shown that when people are involved, decisions are made better and quicker, health outcomes are improved and money is better targeted.
The UK is a leading force in medical innovation and has a history of research excellence, but the uptake of new medicines in the NHS is far too slow, with evaluations and financial approvals significantly reduced. Patient access, therefore, to new medicines is finally balanced on finances. We need to develop ways to improve that situation. Information we received showed that the key is to develop a culture in which innovation can be rapidly adopted and spread across the system, as solutions are found in the intellectual capital of people working in the healthcare system and the patients and citizens who use it.
More preventive care is needed, particularly around screening: screening tests are one of the best ways of engaging the general public. When diagnostic results are produced at an earlier stage people are more likely to survive cancer: the evidence is that more than nine in 10 people survive cancer when diagnosed at stage 1. That has been a great success.
I look forward, also, to the FIT bowel-screening test, which comes online this month. I hope the Minister will tell me that that is still on track. A bowel-screening target has been set of 70% uptake by 2020, compared to just 56% in 2016-17. We need good outcomes.
There are opportunities for improving the quality of services for patients while improving efficiency, lowering costs and providing more care outside hospitals. A strong, progressive capital strategy and investment in the maintenance backlog are also essential. If we accelerate this opportunity in the short term, it will deliver cost savings by using existing premises and in certain areas rationalising the estate to provide outcomes that are better for both patients and the public purse.
The need, therefore, is to develop a really strong, robust capital strategy to determine the investment required. Then we need to take swift action to accelerate change and build momentum in the system, in order to capitalise on short-term opportunities to save running costs and to cut waste through better utilisation of existing premises—even before rationalisation of the estate is initiated. Finally, funding needs to be more smartly targeted in the long term to help deliver a strong public service.
I have mentioned opportunities many times during my allotted few minutes, and I believe that there will be more. We have to act and deliver on those opportunities to provide a robust, safe, caring NHS that is fit for the 21st century—and, importantly, free at the point of need.
Lord Carter of Coles (Lab)
My Lords, I too congratulate the noble Lord, Lord Patel, on his introduction and his excellent chairing of the committee that produced this really authoritative report. We should not be surprised that it is so authoritative when we look at its members: there was clinical input, operational input and political input, all critical for navigating and producing a successful healthcare system. I refer to my interests in the register but will specifically mention a non-executive position on the board of NHS Improvement.
There is a high degree of consensus on the need for long-term funding and planning. Ministers are beginning to listen and the signs are good. We must get away from stop/go: it leads to all sorts of asset misappropriation and degrades the system over time.
I will touch on four points, starting with integrated care. Much has been made of this. Someone said to me the other day that the English system is so fragmented—for many reasons—that it was like having a bad aeroplane journey: you have a bumpy take-off, a pretty smooth flight then a bumpy landing. Getting in and out of the system causes enormous difficulties. We have fragmented it, and we need, in bringing NHSI and NHS England much closer together, to do away with that fragmentation.
A key fault line in the system—as has been mentioned by other noble Lords—is the breakdown between acute care and long-term care for adults. It is a serious problem that is bedevilling the system. There are probably more than 10,000 people in our hospitals who should not be there. The effect is that we cannot perform the elective surgery and the system starts to spiral downwards. If the Government could do one thing quickly—this is about the long term but they need to do some things quickly—it should be to solve the problem of how to move patients out of the acute care system. Perhaps we should look at other healthcare economies, where central, rather than local, government funds the first 30, 60 or 90 days in the post-acute phase.
We need to look at other systems. The other day I was walking around a hospital in the United States with the lady who ran the trauma and orthopaedic department. I asked her what the average length of stay was for a total hip replacement. She looked really put out. She said that it was 56 hours. I said that sounded pretty good to me and asked what it should be. She said that it should be 52. We measure our length of stay in days: it is five and a half days, which is 130 hours. Other systems have developed because they have appropriate people in the care pathway. They have developed step-down care and homecare. In theory, people can move through the system and be cared for in the most appropriate place, both clinically and financially.
Integrated care is crucial, and the point was made earlier: we know how to do this. As someone said, the NHS has done everything right once. The challenge it faces is how to do things at scale: how to take its great skills—something that I will return to—and spread the productivity.
On integrated care and the issue of funding, whether that is a hypothecated tax or whatever, we must mutualise the risk. We do not want individuals bearing the risk and the fear that goes with it. We all agree on that but what form it will take, we will see. The critical point is: how do we involve citizens in the spending of that healthcare money and make them aware of what is spent? Do we take the French system and send them a statement every year saying, “This is what we spent to keep you in the state you are”? Or do we have a system like that of Singapore, where there are individual healthcare savings accounts and the citizen takes an active part in spending that money? Getting the total funding package is right but involving the citizen will be critical if we are to build a modern healthcare system.
I have worked on productivity for some years now in the NHS. It is inconsistent across the whole picture, in terms of not only money but care output and outcomes. Under the CQC ratings, there are 230 provider organisations in England. Of those, 12 are highly rated; 103 are good; 103 need improvement; and nine are obviously in serious difficulty. We have excellent hospitals—excellent community hospitals and mental health providers, and some of the great acute hospitals in the world—but we fail to take the learnings from them and spread them through the system. We are short on some degree of information-sharing and standardisation, although in fact we are quite rich on information. In many ways we do not use it properly or turn it into action, so it is quite critical.
People are beginning to think about this in NHSI. The noble Lord mentioned the work that Professor Briggs and Professor Evans are doing on standardising clinical pathways under the GIRFT programme. We are already gradually seeing the influence of people doing things in common. I think it was Benjamin Franklin who said, on the signing of the Declaration of Independence, “If we don’t all hang together they’ll certainly hang us separately”. What has happened in the NHS is that we have been hanged separately by vendors or suppliers of materials, et cetera, so we need to hang together a little. Where we get that hanging together, we see savings. We have seen that this year in pharmaceuticals, where we have taken £300 million-odd out in the last year just by behaving collectively and switching purchasing in a proper manner.
That leads me finally to the issue of staff. People have talked about training and the need for it. All the time, we hear the praise for our dedicated NHS staff but perhaps we should turn to the annual staff survey and ask ourselves why 25% of the staff across the system feel harassed and bullied. I know of no other healthcare system in the world where that would work; in fact, for anybody involved in employing large numbers of people, anything above 10% is certainly a warning signal. In a good healthcare system, frankly, anything above low double digits is a crisis. We need to go back and understand this. Perhaps the Minister can say what is being done. The report talks about the effect of pay on morale but maybe we need to understand the effect of culture, management and pay on the critical issue, at this time of staff shortages, of how we use that scarce resource.
This report should shake our complacency. We seem to have a sort of schizophrenic attitude to the NHS. On the one hand, we are incredibly proud of it and think it is the greatest thing, yet when we look objectively we are failing. We are not as good as we should be, yet we have the perfect structure. What we need to do is to operate it better and we are beginning to work out how to do that. The question is: can we go at pace and move quickly enough? We need to convince the funders that as the money comes it will be spent wisely, and convince the public that we are spending it sensibly. We are on the edge of that but it will require an enormous push from government to get it there.
Baroness Finlay of Llandaff (CB)
My Lords, this important report is a 70th birthday gift to the NHS—a gift crafted and delivered expertly by my noble friend Lord Patel and his committee. Perhaps the Government’s response reads a little more like a hesitant thank you letter.
We must not forget that the NHS came into being following the Beveridge report and, as Aneurin Bevan entitled his book, it came In Place of Fear. To quote Bevan:
“The field in which the claims of individual commercialism come into most immediate conflict with reputable notions of social values is that of health”.
We must not lose sight of that as we see an NHS in which fields of private endeavour have certainly developed improvements—but some aspects of commercialism, such as PFIs, have left the NHS deprived of its own funding. The recommendations on funding in this report now appear to have been taken up as government thinking, which is a fantastic compliment to the committee.
I would like to briefly address the issue of the workforce across several sectors and touch on opportunities for integration. As the noble Lord, Lord Willis, said, we depend on our workforce. A series of pressures, including Brexit, have compounded the strain felt everywhere. For doctors, particularly those in training, the events following the tragic death of six year-old Jack Adcock have shaken medicine to the core, because in many places the current system does not feel sustainable, with staff working at or beyond the limits of their capacity. This seismic effect has resulted in a loss of confidence in the system and has been felt in primary care. We need a workforce trained for today and for the future. The increased number of medical students is welcome but will probably not be anywhere near enough. We have been far too dependent for too long on importing staff at all levels for health and social care. In our changing world, we know there are predictions of shortfalls at every level.
For patients themselves, accurate diagnosis is essential. Reaching a diagnosis requires not only listening to the patients but picking up all the cues from around them and those who matter to them, as well as their environment. But diagnostic services underpin accurate diagnosis. Let me illustrate this with pathology. Pathologists are at the heart of cancer screening, diagnosis, monitoring and treatment. They diagnose tumours and determine the type of cancer, its grade and responsiveness. Blood cancers are treated by pathologists specialising in haematology. There has been a 4.5% growth in demand for pathology year on year, and longer survival thanks to treatment advances.
The tests to inform treatments are increasingly complex and, as has already been mentioned, screening will put a further demand on pathology—histopathology in particular. However, staffing levels have not risen in line with demand. Ten per cent of posts lie vacant and there is a predicted 25% workforce shortage by 2021 for both pathologists and reporting scientists, even allowing for information technology improvements. The Cancer Workforce Plan predicts that there will not be enough histopathologists in the NHS to deliver its ambitions.
Bevan had hoped that prevention would decrease the pressures of illness. We know perfectly well that it is not either/or but both. Prevention plus early diagnosis and rapid intervention are the challenges for the future. If we are to meet the challenges addressed in the report for better care in the community and freeing up hospital beds, the social care sector itself needs to address its recruitment and retention. Carers need to be registered, with a clear prospect of career progression. The Care Quality Commission has reported that a quarter of care homes require improvement. That cannot be ignored.
The pressure to move patients out of hospital beds into the community is so great that transformation and improvement at a local level is becoming a lower priority, yet it cannot happen without integrated systems. My noble friend Lady Murphy has already addressed this. More money alone will not solve the problem. People who go home early often do surprisingly well, yet our discharge services can be risk averse. People tell us what they need—but they need to be listened to.
Continuity of care is often provided by the social care workforce, who see someone day in and day out. They see the changes and the deterioration. But the problem of lack of integration means that, so often, people are bounced into emergency departments because that is where the lights are on 24/7 and the entrance door is there to other bits of healthcare. Emergency departments have seen an increase of almost 1.5 million attendances since 2010-11, equating to the workload of 10 medium-sized departments. Those pressures are still rising. They have been squeezed beyond the point at which the pips squeak. They know that safety is increasingly compromised. They are dealing with the sickest people, often in sudden crisis, across all disciplines, moving from one resuscitation to another—always calm, compassionate and competent, irrespective of the pressures and the severe distress they manage and the abuse sometimes hurled at them. How can you start a shift knowing that there are no ITU beds and that the hospital is full? The struggle is day in, day out. Some departments are putting in support such as positive reporting, mindfulness and the little things that recognise everybody’s importance. That cup of tea is terribly important.
In my last few moments I shall address a missed opportunity. I declare my interest as vice-president of Hospice UK. Better integration of hospices and the NHS can certainly free beds and result in an up to 40% decrease in the use of hospital beds, with significant savings of more than £1,000 per patient. It can improve quality of life. Yet this is a missed opportunity. We still rely on the voluntary sector to look after the most vulnerable at their most vulnerable time. The silos have to go. This important report needs action and its recommendations must be taken forward, underpinned by a radical commitment to a National Health Service. The NHS reaches three score years and ten this year, but it is not near the end of its life. This can be the beginning of a new era, developing from Tredegar and Bevan’s dream.
Baroness Bloomfield of Hinton Waldrist (Con)
My Lords, I, too, add my congratulations to those of other noble Lords to the noble Lord, Lord Patel, and his team on this excellent report and its thoughtful, challenging recommendations to Her Majesty’s Government.
I have been exceptionally lucky in all my experiences with the NHS. An early diagnosis through a national screening programme and rapid follow-up led to successful treatment at the Royal Marsden, and here I defend from my noble friend Lord Prior its record of working with private, transformational biotechnology firms, such as Immunocore. I received a humbling level of capable, compassionate and cheerful care from everyone—just what one would want from the NHS for everybody.
However, I recognise my experience is not matched by that of others around the country. In many regions, the service is creaking under the weight of demographic challenges, patchy social care provision leading to late discharges of the elderly and increasingly expensive treatments. This is combined with overwhelming expectations of what we should expect of the NHS in the 21st century, and as wonderful new treatments emerge for hitherto untreatable conditions this pressure is likely to increase.
I believe that, broadly, we all want the same thing: excellent care for all, free at the point of need. We may differ in the way we believe we can achieve it, but we are all motivated by the long-term vision of delivering better care more affordably, and I agree wholeheartedly with the noble Lords, Lord Patel and Lord Willis, that a long-term plan can be achieved only through political consensus.
The guiding principles of the NHS state that:
“the NHS seeks to improve the health and wellbeing of patients, communities and its staff through professionalism, innovation and excellence in care”.
I want to focus my few comments on innovation, particularly technical innovation in the healthcare sector. This area comprised only eight pages of the report in a chapter that included productivity. Here I should declare my interest inasmuch as two of my children work in health tech, for eConsult and Lantum respectively. The former provides online GP services within the NHS, and the latter produces a workforce management tool connecting healthcare professionals with providers.
Heathcare is facing the kind of transformation not seen since the discovery of antibiotics and anaesthetics. Indeed, harnessing technology and digital innovation is critical to its long-term future. There is scarcely an area of medicine that cannot be improved upon by new technologies. Many of them can also have a transformative impact on disease prevention. In the energy market, which I know rather better, my view has always been that conserving energy is at least as important as energy generation in closing the energy gap, and so it must be that preventing illness will be a significant factor in narrowing the funding gap within the NHS.
Some £10 billion of the health service budget is currently spent on diabetes. NHS England’s pilot of digital diabetes prevention programmes is a good example of a national focus on tech. There were 87 applications for the five places for the trial, and the successful bidders to be investigated and trialled include Buddi Nujjer, Oviva, Liva Healthcare, OurPath and Hitachi. If we could only diagnose diabetes earlier and educate people into healthier lifestyles, it would lead to a lighter burden for the NHS as well as a better quality of life for patients. Simon Stevens commented:
“So much else in our lives is now about online social connection and support, and that now needs to be true too for the modern NHS. This new programme is the latest example of how the NHS is now getting practical and getting serious about new ways of supporting people to stay healthy”.
Depressingly though, both the chief executive of NHS Digital and Nicola Blackwood, in her report for PUBLIC, The Promise of Healthtech, talk of a silo mentality and technology inhibitor which discourages the uptake of new technology at scale. PUBLIC’s survey last year commented that,
“If startups take twice as long as you expect, healthcare startups take five times as long”.
Poor procurement practices are a major barrier to entry in certain parts of the country and in certain parts of the NHS. Many still rely on large IT vendors which fail to meet modern standards of interoperability. Cultural resistance, digital skills and the willingness to embrace technology also vary enormously across the NHS, so new companies need to understand issues of regulatory compliance and have evidence of clinical value in order to sell into the NHS successfully. Those that succeed will have focused their attention on areas where the NHS is most receptive to new technologies.
Primary care is an example. More care needs to be delivered through digital health solutions, giving GPs the time and ability to monitor and nudge behaviour remotely. Online consultations with GPs are now commonplace with companies such as eConsult. It was formed by a consortium of NHS GPs and helps to increase the capacity of GPs to see an ever-growing number of patients with increasingly complex health issues. Its remit includes spreading best practice throughout the country. Although there are still many sceptics within the profession who remain hostile to change, it is anticipated that by the end of this year many NHS patients in England will have digital access to their GP.
Dr Murray Ellender, writing in the Times earlier this week, stated that modern digital triage tools can now help to differentiate between serious conditions necessitating a face-to-face consultation and the more routine which can be dealt with remotely. Although he observes,
“if we use social media as a benchmark, digital consulting is still at the Friends Reunited … stage”,
there are grounds for optimism. The current cohort of digitally savvy medical students and the recently qualified are sure to be rather quicker to embrace new technologies than their perhaps less digitally aware seniors. The changes that innovations such as cloud computing, VR, 3D printing, genomics and AI are bringing to the NHS could not have been imagined even five years ago and, frankly, cannot come a moment too soon.
Lord Winston (Lab)
My Lords, I thank the noble Lord, Lord Patel, for obtaining this debate and for his excellent report. I declare just one interest as a fellow of the Academy of Medical Sciences, and it is in that capacity that I want to speak in this debate to follow what the noble Baroness, Lady Bloomfield, said.
To extend the coverage of this report, we perhaps need to consider academic medicine a bit more carefully. Sir Robert Lechler, the president of the Academy of Medical Sciences, has written that the identification, training, development and retention of a new breed of clinical academic and research staff is essential for the NHS and UK science. They have to be digitally aware and properly trained in those things as well. He added that the academic health science centres, which were started some 12 years ago, have a clear role in the future of healthcare research and should be valued and should continue to be supported to be as effective as possible.
One of the issues is staff retention at those academic healthcare centres. This is a major problem. For example, in London, as I think I rather wryly pointed out to the noble Lord, Lord Prior, on one occasion when he was responding to a debate, after 12 years we are still looking for a professor of reproductive medicine to fill the chair that I left. We just cannot find anyone because of the expense of living in London and because, in this sector, the market has ensured that people are not working in academe or the NHS; they have gone private. I will come back to that point in a second. So this is critical, and we need to ensure new work practices and models for care delivery, and they have to be supported through research. In my view and that of the academy, that will require protected research time for medical professionals and the maintenance of funding. In particular, that must mean research for consultants, particularly in teaching hospitals.
We often boast about the advances that we have made in this country in medical care. The list is significant: organ transplantation, of course, thanks to Peter Medawar; antibody research, which has been mentioned; cancer research; and treatment for HIV. MRI and ultrasound were both started in this country. University College London is leading in some of the advances in neuroscience. In my own field, in vitro fertilisation and the screening of genetic disease were started in this country.
It is interesting to consider that we debated mitochondrial treatments for families with these diseases three years ago, in February 2015, and we agreed that that should be done. Three years later, as far as I am aware, there has not been a single treatment. Why should it take so long to get permission to do that when we have agreed in Parliament that it is essential? Think of those families who are waiting as a result of that research and those who have watched the child die of a horrible disease within the first two years of life. That seems wrong to me, and we should recognise that we need to implement our research in every field that we can.
One of the problems is something that I think was started by the Tory Party, although the Labour Government supported it: the internal market. Once we had the internal market, we could not centralise expertise in the way that we had before. We were able to develop very large patient bases, we could have better research and data, we could have much better trials and we could have training for people who could then go out to other parts of the country and improve what was going on in the health service.
A key issue is the need for young medical scientists. It is a major problem that lecturer posts, which are essential for research, are too few in this country and not fully supported, and often it is very difficult to make certain that you are going to get continued progression up to senior lecturer level. It used to be a huge advantage in medical research to have a PhD with an MD degree, but you could argue that it is now a disadvantage. We have young scientists who find that they cannot do clinical research in their hospitals because the NHS is just too difficult and too pressurised for them to do that at the moment. That is a massive problem.
As has been said repeatedly in this debate, we should also be looking at people as well as projects. It was interesting to read the article by the noble Viscount, Lord Ridley, in the Times this morning about the 100,000 Genomes Project. Of course it is a very interesting project and it may lead to important data, but as yet that has not been validated. We need to understand that we have to have investment in young people who are going to do the research. That is very important.
Time is short in this debate and I do not want to go on at great length, but I hope that, rather than just a complacent answer—I do not mean in any way to be discourteous—we can have an assurance from the Minister that we will see the academic health science centres, which have been such a success, continued. The one at Imperial College is a model for lots of reasons. It does many of the things that we have been saying in the report, such as collaboration: physicists, engineers, chemists, mathematicians and economists as well as medics work side by side to ensure that the research is promulgated and pushed in the best possible direction. However, those centres are fragile, and we need to ensure that the funding is secured and continued for the long term. If it is not, it is going to be very difficult to maintain the excellence in the health service, which I think will fall. The same must apply to the huge success of NIHR, which has been a massive advantage to research and is another form of collaboration. I hope the Minister will give us assurances on this point.