(6 years, 5 months ago)
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Lord Darzi of Denham
That this House takes note of the creation of the National Health Service in 1948, and the case for integration of health, mental health, social and community care to equip the National Health Service for the next 70 years.
Lord Darzi of Denham (Lab)
My Lords, in opening this debate, I declare my interest. I am a practising surgeon in the NHS at St Mary’s Hospital, Paddington, and the Royal Marsden and am the chair of surgery at Imperial College. I proudly sit as a non-executive director of NHS Improvement. Over the past 10 months, I have led an independent review of the health and care system with the Institute for Public Policy Research.
As a surgeon and a former Health Minister, it is a great honour to speak in this place to mark the 70th anniversary of the National Health Service. The NHS is this country’s most treasured institution. It touches our lives at times of the most basic human need when care and compassion matter most. This is a time for reflection to celebrate the institution and give thanks to NHS staff for their service to our nation, and to look to the future.
The NHS is the expression of the moral principle that no one should be denied healthcare because of their means—the idea that the provision of healthcare should be based on need and not the ability to pay. Most people alive today cannot recall the time before the health service was created. With each passing year, the number of people who can recall the pre-NHS era recedes, but if we are to secure its future we must never forget what preceded it.
A friend recently told me the story of his family. His parent worked in the textile mills in Lancashire that have long since disappeared. In the simple kitchen there were two sugar bowls. One was for the sugar and the other for the doctor. It was where they would save a penny or two whenever they could so that, if any member of the family got sick, they could pay for a visit to a doctor. Fear of falling sick was a normal part of daily life in Britain. Illness was the surest path to poverty and destitution, not just for the individuals but for whole families. The founding of the NHS took that fear away for millions and it is a fear that those of us born since have never known and can only imagine.
The NHS was the greatest achievement of the post-war Labour Government. We owe an eternal debt of gratitude to Nye Bevan for his vision, passion and determination to establish the health service. He memorably described the NHS as taking the place of fear. It remains one of the most extraordinary achievements of any society anywhere in the world. It is on occasions such as the 70th anniversary that we must make and remake the case for comprehensive, universal healthcare, free at the point of need for all.
Never let anyone tell you that we cannot afford the NHS. The moral principle of universal access to healthcare is shared by all people everywhere. Those countries that have made it a reality have done so in different ways, but by far the most efficient, dignified and lowest cost is to create a universal service free at the point of need funded by taxation. Private insurance and social insurance systems are much more costly. Those who argue that we cannot afford the NHS are seriously wrong. It is a fundamental error of logic to say that something is unaffordable so we should make the move to something more expensive.
The NHS is funded by us all. It serves each of us and it reflects the best of us. The health service employs 1.5 million people across the four nations of the United Kingdom—that is 5% of all working people in our country. The NHS is its people, not only the doctors and nurses but clinicians of all kinds and the porters, cooks, cleaners and, yes, the vital managers and administrators too. Spending a day working as a porter in the NHS was one of the most illuminating moments of my career. Every member of Team NHS matters. Every one has a contribution to make and each is valuable. I pay tribute to the NHS employees of today who are my colleagues, and to the NHS staff of previous generations. On this day of thanksgiving, we owe them a lasting debt of gratitude.
I have worked in the NHS for longer than I have been a citizen of this country. In a time of great anxiety, I pay a special tribute to the citizens of other countries who have helped to build our NHS throughout its existence and remain the backbone of it today. From the Windrush generation to the European citizens and nationals of every race and creed, from every corner of the world today, they have made an immeasurable contribution. Let that never be forgotten.
NHS staff work at the frontiers of innovation because healthcare exists at the limits of science. This country is a scientific superpower with an extraordinary record of discovery and invention, yet in recent years we have fallen behind on investments in R&D. R&D is the engine of innovation yet R&D spending as a share of GDP has been falling while our competitors have invested more. We need a new commitment to be at the top quartile of advanced countries for R&D investment. The future prosperity of our country depends on it.
Many of the most important medical discoveries took place in this country, often through partnership between the NHS and the universities. No matter the challenges, we are constantly finding new ways to treat disease and soothe pain and suffering. That means that high-quality care is constantly a moving target: to stand still is to fall back. What energises NHS staff is relentlessly improving the quality of care they deliver to their patients. In my review of the NHS with the IPPR we found that, on a wide range of measures, the NHS has maintained and improved the quality of care it provides. Fewer people are harmed and more people are cured than ever before. There is a huge amount to celebrate and to be proud of, yet we should frankly acknowledge the difficulties the health service has faced. The past decade has been the most austere since the health service was founded. Waiting times have risen considerably and the system has been subject to needless destructive reforms. The NHS is not failing, but it is fragile.
A properly funded NHS is the foundation on which a fair, cohesive and inclusive society is built, so the new funding settlement announced by the Prime Minister, the Chancellor and the Secretary of State for Health is very welcome. My friend the noble Lord, Lord Prior, and I, together with the IPPR, recommended a 3.5% annual funding increase: the Government came close, with 3.4%. However, the settlement did not include public health, capital investment or education and training. Each of these is vital and the Government must now deliver on them too.
Securing the NHS is an eternal task. It is no more perfect than life itself. That is why new investment must be joined with reform. Together with the noble Lord, Lord Prior, and the IPPR, I set out a 10-point plan for a 21st-century NHS. At its heart is a new vision, what we call “neighbourhood NHS”, where services are organised around groups of patients with broadly similar needs, rather than groups of professionals with broadly similar skills. We argue that there should be a new option for single integrated care trusts, able to take responsibility for all the health and care needs of a population.
Warm words on mental health must be followed by bold actions. Parity of esteem should mean parity of service. Bringing care closer to people is a crucial principle for a modern NHS, yet for too long the NHS has said it would invest more in care closer to people yet continues to do the inverse of its stated strategy. Each year we say that resources will shift and each year they flow upwards towards hospitals rather than outwards towards communities. That is why we must lock in more spending on primary, community and mental health services each year in the decade ahead.
As we celebrate the past on this anniversary day, we must also look to the future. It is our duty to seize all the technological opportunities that this new era offers. There must be a tilt towards tech to create a digital-first health and care system. That will demand investment in digital infrastructure, improved data sharing and embracing full automation. Many people fear that automation will destroy jobs, but it is much more likely to reshape them by taking away mundane tasks that fill most of our time working in the NHS. This will release more time to care and give more space for clinical reasoning, for research and for innovation.
I have spent decades developing robotic surgery. The robots have yet to replace me, but they have helped me deliver higher-quality care to my patients. For all these improvements to happen, we need a radical simplification of the system. It has become impossibly complicated and is in desperate need of change. I therefore welcome the Prime Minister’s commitment to bring forward legislative change. Tinkering at the edges will not be enough: we need fundamental reform. Above all else, we need to confront the great social challenge of today, which is social care, as we heard earlier.
When the NHS was founded, life expectancy for men was 66 and for women it was just 71. Today, it is 79 and 83 respectively. Today, one-quarter of NHS beds are occupied by patients who are medically fit to go home, if there were good enough support for them. More than £3 billion a year of NHS money is wasted by delayed transfers or transitions of care. If Bevan were designing the health service today, it is unimaginable that he would have excluded social care. We must now extend that simple, noble, brilliant principle of care based on need rather than the ability to pay from the NHS and apply it to social care.
Social care reform has become the third rail of British politics: any politician touching it swiftly expires. Between now and 2030 the number of people over the age of 65 will increase by about one-third and the number of those over 85 will nearly double. At the same time, the working-age population will increase by just about 3%. If we do not act now, a heavy burden will fall on families to take care of their relatives. Since 2010, social care has been slashed. Despite rising demand, state social care has plummeted by 27%. That does not mean that less care has been provided. There has been a dramatic rise in informal care. Critics will argue that the older generation should contribute more of their wealth to pay for social care, particularly the wealth locked up in housing, but tying social care reform to the thorny issue of wealth inequality and taxation is wrong. If we make that hurdle for social care reform, there will be no progress at all. Surely, the level of personal wealth is a better basis for wealth taxation than the need for social care.
Better social care means that families spend less time on functional tasks and more time on relationships. If we want a less lonely and more dignified future for our ageing society, now is the time to act. There could be no better birthday present for the health service. It has been a privilege for me to open this debate, but it has been the greatest honour of my life serving the National Health Service for nearly 30 years. In 30 years from today I hope to see the NHS’s centenary. It is a great comfort to know, for me just as for all of us, that the NHS will be there to provide care and compassion when it matters most.
Baroness Manzoor (Con)
My Lords, to assist the House, I say that Back-Bench speeches are limited to four minutes so, when the clock strikes four, time is up.
Lord Ribeiro (Con)
My Lords, I thank the noble Lord, Lord Darzi, for introducing this important debate. It is a privilege to follow him, as a fellow surgeon. The debate marks the 70th birthday of the NHS and the social care system, and the role that Aneurin Bevan played in it. Making our health service free at the point of need and use while social care remains means-tested has created an unfair system. Equal opportunities and the emancipation of the workforce has meant that an army of carers which used to exist to look after one’s own is no longer there, and increasingly we turn to care homes for our elderly.
The noble Lords, Lord Darzi and Lord Prior, in their excellent report Better Health and Care for All, published in June, focused on social care, public health and life sciences. This debate makes the case for integrated health, mental health, social care and community care. The creation of a Department of Health and Social Care this year is a welcome first step in recognising the importance of integration. This report makes the case for releasing time for health professionals to care and makes a plea to trust the judgment of professionals. These words are welcome in a health service where professionals feel that top-down management calls the shots, rather than those at the coalface—that is not meant to be a reference to Tredegar.
The challenge for government is to extend the principle of need and not the ability to pay to social care and to fully fund the service as part of a new social contract between citizen and state. We await the Government’s Green Paper on social care, alongside the NHS plan, in the autumn with keen interest, mindful that in the past 20 years, with 12 Green Papers and White Papers and five independent commissions, successive Governments have kicked the can down the road when social care reform is considered. The Government accepted the proposals in the Dilnot report of 2011, albeit with a different cap, yet in 2018 we do not have any action on them. I am sure that my friend, the noble Lord, Lord Warner, will say something about that in his speech. Can we expect a definitive statement on this, along with the Green Paper, in the autumn?
There also needs to be a paradigm shift in the model of urgent and emergency care, the workforce to deliver it and the contribution of patients to manage their own health. The days of “doctor knows best”—let alone politicians or managers—are over. As chairman of the Independent Reconfiguration Panel, which advises the Secretary of State for Health on contested service change, I know that a sound clinical case for change is necessary but not sufficient to achieve change. For that to happen in the future, the views of patients and the public must lead the decisions about their health and healthcare. The challenge, as always, is how to achieve that in a meaningful and effective way.
Lord Winston (Lab)
My Lords, it is a great pleasure to congratulate my noble friend—and respected colleague at Imperial College—Lord Darzi on the outstanding way he introduced the debate. I was just talking to the noble Lord, Lord Reid, in the Bar and he said that sometimes you tear up the speech that you have written. This is one of those occasions.
At 8.40 am today, my grandson was born at Queen Charlotte’s and Chelsea Hospital under the National Health Service. My daughter had a horrendous pregnancy four years ago. I went through every single red light in London, I think, on my way to Queen Charlotte’s, when she had the most serious obstetric emergency and could have died. In fact, both she and the baby, Ellie, survived and are well, and she had this last pregnancy by elective caesarean section. It is striking that the National Health Service has been an example of the most amazing care. When I took her into Queen Charlotte’s the first time, she was delivered within 13 minutes of arrival on site and they did not even recognise me, even though I had helped design the building in which she was being delivered. That is a great credit to the health service.
Today there was a slightly different welcome when I drove up to the car park. It was completely blocked by television cameras, with various news media filming Queen Charlotte’s in all its panoply of glory, accompanied by wonderful, syrupy comments about the National Health Service. While I was hoping to hear a baby cry in the operating theatre next door, I was watching the coverage on television as an example of exactly what we do not need. My noble friend Lord Darzi was completely right, in the humble way he introduced the debate, to point out how magnificent the health service has been, but it is also important for us to be realistic. There is a major problem that we have to face and it is often easy to be really quite untruthful about the impact.
We are not having a proper debate about the health service in this country. I mean no disrespect to the Prime Minister or anybody else but we cannot continue on handouts. Both parties have been equally responsible. We always claim on this side that we invented the health service. I remember that when the dreadful internal market was brought in by Margaret Thatcher, Frank Dobson, the shadow Health Minister, promised he would abolish it. He did not when we came into power. We still have that iniquitous system, which is costing the National Health Service millions in bureaucracy and all sorts of other things, and of course resulting in health inequality, with the postcode lottery and many other examples.
We have to recognise that we need to have an honest debate and the only way we can do this is to depoliticise the system and the argument. We have to recognise that on all sides of this House we agree about the value of the National Health Service. We all realise that it is a remarkable and unique but fragile organisation. We need to do something about recognising that first we have to agree on a proportion of gross domestic product to understand how we are going to fund it before we consider taxation or any other form of spending. We have to understand how much it actually costs and at the moment, with that internal market, sadly, we do not know that. That is a major problem for us and something that I hope we will look at.
My noble friend Lord Darzi reiterated a very important point that I made in a debate about a month ago when I pointed out the importance of academic healthcare and the academic science centres. This is something which really is unique in the health service and unless we continue with that aspect of science, there will be a problem. So we have to weigh that in the balance of how we fund the health service in the future.
Baroness Tyler of Enfield (LD)
My Lords, I congratulate the noble Lord, Lord Darzi, on securing this extremely timely debate, and pay tribute to the wonderful work and care of all staff in both the health and social care sectors. I will start with my favourite Bevan quote before someone else gets it in. Back in 1948 he said:
“Illness is neither an indulgence for which people have to pay nor an offence for which they should be penalised, but a misfortune the cost of which should be shared by the community”.
How do we reinterpret this incredibly important founding sentiment of the NHS in the modern age and over the next 70 years?
Recent polling by the King’s Fund shows that the British people have a great deal and pride in and good will towards the NHS. Despite this, securing proper long-term investment to achieve a fully integrated health and care service has sometimes felt like pulling teeth. Yes, the Prime Minister announced that the NHS would get a 3.4% yearly rise for its birthday and of course that is to be welcomed, but we cannot ignore the fact that the often-cited 4% necessary to even maintain existing standards, let alone improve and transform services, is still some way off. Sadly, as others have said, this new long-term funding settlement has so far ignored social care and public health and there is no clarity on what proportion of this money will go into mental health care—something I hope the Minister will be able to help us with this afternoon.
To meet increasing demand, the NHS will need more than just money: it will need a wholesale shift to promoting health as well as healthcare, to ensuring wellness rather than just treating illness, and to integrating health services so that they can be centred around the individual and the holistic needs of each patient. It came as no surprise to read in the Guardian last week that keeping the same doctor improves a patient’s life expectancy. This is great news so why is it so often not the case?
Turning briefly to social care, as we have just heard, continuous cuts, coupled with chronic long-term underinvestment, have left social care in a dire state. In their recent report, What’s the Problem with Social Care, and Why Do We Need to Do Better?, four leading health and social care bodies reported that to qualify for publicly funded social care, someone now needs to be 12% poorer than eight years ago. Meanwhile, informal carers continue to carry the bulk of the burden. The IPPR estimates that insufficient social care costs the NHS £3 billion a year, and with an ageing population these costs are bound to increase. If we are serious about safeguarding the NHS and its future, social care needs its birthday cake, too, and it needs to be a big one.
Turning to public health, in their recent report, The NHS at 70: Are We Expecting Too Much from the NHS?, those same four health bodies again emphasised that the most important factors in people’s health and life expectancy relate to the economic, physical and social environment in which they live. Therefore, public health must be made a priority if we are to have a healthier population.
Mental health is starting to get the public attention that it deserves. A recent Ipsos MORI poll found that the public rate it as their second-to-top health priority, which is great—but it is critical that those money increases are accompanied by mental health services that are much better integrated with physical health, community care and social care. So when the Minister winds up, perhaps he will tell us whether he feels that it is acceptable that currently only some one in four people with a mental health problem is able to access treatment, and what plans the Government have to increase this—and, specifically, what percentage of the new money announced for the NHS will go to mental health.
I conclude by saying that a good way of addressing all the issues that I and others have raised today will be to reframe the way we talk about the NHS as a national wellness service rather than one that just treats illness. I like to think that Aneurin Bevan and Beveridge would approve of that sentiment.
Lord Mawson (CB)
My Lords, I thank the noble Lord, Lord Darzi, for introducing this important debate. My colleagues and I have been at the cutting edge of the integration agenda for 35 years now. We are today generating a national and international movement and infecting the NHS culture. This year we have welcomed leaders from 23 countries across the world to see our work. Today I am taking our experience to 10 cities and towns in the north of England, through the Well North programme, which I have been asked to lead by the CEO of Public Health England. I declare my interests.
If we are to have an NHS in 70 years’ time, we suggest the following steps, based on hard-won practical experience. First, we must return to the fundamental question raised by the Peckham experiment in 1948, “What is health?”. The NHS closed this project in 1952, saying that its services would now be delivered by the NHS. It was wrong. Some 50% of our patients today do not have a biomedical problem: they have a housing, education or employment problem, or they are lonely. I am finding similar numbers in communities in the north of England. The Bromley by Bow Centre is Peckham mark II, but this time with a business plan.
Secondly, we should stop building health centres. Today we offer a vast array of services to our local community and our 40,000 patients. They stretch from conventional healthcare for local residents to opportunities to set up your own business, from support with tackling credit card debts to help with learning to read and write and help up the career ladder. We should stop building health centres, but that is not to denigrate clinical health. On the contrary, we need to position clinical health within a broad range of services to drive well-being in communities.
The list in this debate question is far too limited. We need to create a locally blended offer, where doctors sit alongside others, including patients and local residents, to provide what people need. It is healthier for doctors. Our health centres are more like a John Lewis store, where the customer is welcomed in and a host of choices are laid before them. The people who run successful department stores know that a diverse product range makes complete sense for the customer and financial sense for the business. You can capture the customer and have an opportunity to offer myriad products and services. It is the same principle in integrated holistic centres, where health is about life and living, not just disease and illness. It is about sweating our community assets. This approach would create benefits and savings across a range of Whitehall departments, not just the Department of Health.
We are working with our partners to build two new town centres in Rotherham and Stocksbridge, just outside Sheffield. The retail sector is challenged at the moment by the internet, but there is a real opportunity to rethink what a town centre is and to put the heart back into it. We will require flexibility and imagination from the NHS and other government departments.
Thirdly, over the years we have developed many innovations that have quietly gone national. The latest is the social prescribing movement which we founded in Bromley. It is now in 20% of GP practices nationally and 80% in Tower Hamlets; there is a network of 2,000 social prescribers across the country. Social prescribing should be the norm in every practice, because it focuses on what matters to patients rather than what is the matter with them. It also ensures maximum engagement with patients in managing their own health. Let us unleash healthy communities.
Finally, there is too much focus on beds and hospitals rather than on early intervention. People believe that the NHS will solve their health problems; often it will not. We are breeding a massive dependency culture through an institution that I would suggest is far from well. Let us be honest. It is not lack of resources that is the problem, but what we have chosen to focus on. I fear more of the same. What happened to the five-year plan? It is time to be more radical. Let us drop the sentimentality about the NHS and return to the fundamental question: what is health in the modern world for our children, in a society that is increasingly atomising? I agree with the noble Lord, Lord Darzi. It is time for fundamental reform, based not on sentiment, theories or ideology but on practical innovation and experience on the ground—and it cannot be led simply by the vested interests of the medical profession.
Baroness Manzoor
My Lords, we must keep to time, otherwise noble Lords at the end of the debate will not get their full four minutes.
Baroness Morris of Bolton (Con)
My Lords, I am delighted that the noble Lord, Lord Darzi, has not been replaced by a robot, and I thank him for the wonderful way in which he introduced an important debate on an important day. Like many people in our country, I owe a huge debt of gratitude to the NHS. It nursed me back to health when I broke my back in a riding accident at the age of 17, and today the brilliant rheumatology and orthopaedic departments at Guy’s and St Thomas’, along with my exceptional GP Stephen Liversedge, literally hold me together and keep me physically and economically active. I congratulate the noble Lord, Lord Winston, on the birth of his new grandchild. Three weeks ago my daughter gave birth to my grandson at St Thomas’. I cannot praise the community midwives and the staff of St Thomas’ who looked after her highly enough.
It is hard work not being well, especially as you get older or suffer economic hardship alongside being poorly. In the mid-1990s, when I was deputy chairman of the then Salford Royal Hospital NHS Trust, I would regularly pop into the hospital at weekends to speak to visitors, patients and staff when they had a bit more time to talk and were less stressed. Invariably, at the top of their health concerns would be worries about not being able to park, difficulty getting transport to hospital, childcare while they were in hospital or visiting, weariness at constantly having to explain their symptoms and their circumstances, fear of losing their independence and their job and fear of not being able to cope with the financial burden of recuperation or to care for themselves or their relatives when they returned home. Much of this is beyond the control of the NHS, but all of it is an important ingredient in the recovery and well-being of patients and their families. That is why it is crucial that we bring together as many services and patients as possible, taking a holistic view that puts people at the centre of decision-making.
In 2015 the 37 NHS organisations and local authorities in Greater Manchester came together to form the Greater Manchester Health and Social Care Partnership and signed a ground-breaking agreement with the Government to transfer the management of these services to Greater Manchester. The Government’s enabling legislation, the Cities and Local Government Devolution Act 2016, made this a reality. In one of its documents, the partnership said:
“Our health and social care reform is built on the need to reimagine services across our whole care system”.
I am delighted to say that, in my home town of Bolton, which is one of the 10 metropolitan and city councils that make up Greater Manchester, reimagining began on Tuesday with a decision by the council and the NHS to work together to take steps to join up health and care. I wish them well.
This builds on an already established and visionary partnership between the council, the NHS and the University of Bolton, which in 2012 saw the opening of Bolton One, a £31 million health, leisure and research centre. Our universities, with their research facilities and training in new ways of working, are vital in this mix of integrated care—and it is not just universities with medical schools but all universities across the country that are delivering excellent work in health and social care. I hope noble Lords will indulge me if I single out the University of Bolton, where I served as the first chancellor, for being ranked number one in England for teaching quality across its nursing courses in the Times and Sunday Times Good University Guide 2018.
I cannot begin to imagine what the future of the NHS will look like, with new technologies and redesigned services. But the one constant will be the dedication and experience of the people on the ground, doing the job and working so hard to look after us and keep us well. I pay tribute to them and wish the NHS a very happy 70th birthday.
Lord Pendry (Lab)
My Lords, I, too, congratulate my noble friend on initiating this important debate. It is true that the National Health Service has grown under successive Governments, but currently the growth is slower than at any time in its history. Even the latest cash injection, recently announced, will, in the view of many health service organisations and influential experts, including the Association of Directors of Adult Social Services, the MS Society and the local government society are saying that it is clearly disappointing, that funding is at a standstill and that it is a sticking plaster at best.
The statement from the Prime Minister that social care must wait until 2020 for extra funds—which will not be additional to the £20 billion injection—beggars belief. Where, however, does that leave the Secretary of State? During the debate of 25 January I congratulated him on standing up to the Prime Minister with his implied resignation threat. However, when he was appeased with another string to his bow—the addition of social care to his title—he backtracked. I, and no doubt he, along with others, believed that that would bring extra cash on top of what came with his previous title. Since then, the Prime Minister has made it absolutely clear—Green Paper or not—that no extra money will be forthcoming. Surely Mr Hunt expected more money—for mental health issues, obesity, carers and the vulnerable in our society—when he threatened resignation.
The honourable thing to do, surely, is to adhere to his earlier threat and resign. Ruling out any increase in social care until 2020 makes a nonsense of giving the Secretary of State the additional handle of social care. By definition, that means extra responsibilities and funding now. That is what I thought when we debated the National Health Service and social care in January and I said that the Secretary of State had a golden opportunity—when the Green Paper comes to light—to prove his critics wrong and produce a meaningful improvement in social care provision. Unhappily, however, the Prime Minister has done it again: another promise not kept.
As the noble Lord who introduced this debate said, in a debate of this kind it is important to remind the nation—especially on the 70th birthday of the NHS—that it was Clement Attlee’s Government, and no other, that brought to life the National Health Service, and hopefully to end for all time the lie espoused by Jeremy Hunt at the last Tory party conference, when he claimed that the Tories, and not the Labour Government, invented the National Health Service. History books, and Hansard, clearly show that it was Aneurin Bevan who introduced the first comprehensive national scheme in 1948, when Tory luminaries Winston Churchill, Anthony Eden and Harold Macmillan—all former Tory Prime Ministers—were among other Tories who voted against the implementation of this bold policy. The result of that vote was an enormous victory for the Labour Party and for the nation. I hope that this gigantic lie by the Secretary of State will be laid to rest for ever.
The Lord Bishop of Carlisle
My Lords, I too am most grateful to the noble Lord, Lord Darzi, for securing this timely debate. On the one hand, I am grateful because it is an opportunity to recall and be thankful for the establishment of the NHS in 1948 as one part of a comprehensive vision of social welfare—which, incidentally, owed much to the insight and energy of Archbishop William Temple and other Christian thinkers and activists. Temple and Beveridge were close friends, and much of the post-World War II vision that led to the creation of the welfare state by Bevan and others emerged from church-led consultations.
On the other hand, I am grateful for the clear emphasis in this debate on integration. Our word “health” comes from an Old English word meaning “wholeness”, and the Old Norse version of that word meant “holy” or “sacred”. From the start, when churches and monasteries founded our first hospitals, healthcare has been understood holistically. There is a real sense in which our National Health Service should include caring for all aspects of well-being in all our people. Certainly, in the Select Committee report on the long-term sustainability of the NHS the word “integration” appeared several times.
In the brief time available, I will suggest two aspects of healthcare that fall into the community care category, and which, like mental health and social care, urgently need integrating with other parts of the NHS. The first and most obvious is public health. Here I declare an interest as an associate of the Faculty of Public Health. Other noble Lords have raised this and I am sure others will. I will not, therefore, dwell on it, but from a purely financial point of view money spent on prevention bears obvious dividends: it is never wasted. From a well-being angle, furthermore, prevention has always been better than cure and always will be, especially in relation to our consumption of food and alcohol and our commitment to taking exercise.
The second aspect is spiritual well-being. The World Health Organization understands spirituality as,
“an integrating component, holding together the physical, psychological and social components of a person’s life”.
It is often perceived as concerned with meaning and purpose. For those nearing the end of life, this is commonly associated with a need for forgiveness, reconciliation and affirmation of worth.
Delivery of spiritual care is the responsibility of all professionals in the multidisciplinary healthcare team. This debate, however, provides the opportunity to affirm the vital role of healthcare chaplains, who minister to the spiritual needs of those from all religions and none.
Underlying all this is a significant question of responsibility. Who is responsible for making all this integration happen? We ourselves have an obvious responsibility, as every citizen does, when it comes to prevention but with regard to the integration of physical and mental health with social and community care, do we look primarily to NHS England, regional STPs, local trusts or Parliament to take a lead? I would be most grateful for the Minister’s view on this. There is also the question of consultation. The foundation of the NHS followed a comprehensive and inclusive debate in UK society. Are there any plans for a similar process of inclusive debate, in which all voices are heard and all concerns addressed, as we look forward to the next 70 years of our invaluable National Health Service?
Lord Lexden (Con)
It is an immense pleasure to follow my favourite Bishop. Fortunately, none of the others are here to learn that I care for them less.
I would like to offer a few reflections on the historical background to this important debate, introduced so memorably by the noble Lord, Lord Darzi. I am a historian and a few words about what happened in the 1940s would perhaps not come amiss. I should say at the outset that I take a view very different from that of the noble Lord, Lord Pendry.
In this very month 74 years ago, the then Minister of Health broadcast a message of historic importance to the nation about the Government’s plans for a national health service. He said:
“Whatever your income, if you want to use the service … there’ll be no charge for treatment. The National Health Service will include family doctors whom you choose for yourselves, and who will attend you in your … homes when this is necessary. It’ll cover any medicines you may need, specialist advice, and of course hospital treatment whatever the illness”.
It was with these words in July 1944 that Henry Willink, the Conservative Minister of Health in Churchill’s wartime coalition, heralded a new era in which comprehensive health services would be available to all, free at the point of use. It would be the fulfilment of the vision that Neville Chamberlain, a formidable Health Minister in the 1920s and the greatest of all Tory social reformers, had hoped would one day be accomplished.
Willink set to work. The British Medical Association swiftly assumed the role that was to become so familiar to British politicians over the years, putting the self-interest of its members before all other considerations. Willink was an able but emollient man. He made many concessions to the BMA, though without weakening the Tory commitment to the principles of universality and free delivery of services underlined in the 1945 Conservative election manifesto.
Today, no one remembers Henry Willink, who gave up politics in 1948 to become the master of a Cambridge college, while enduring fame is attached to his successor. Nye Bevan fought the BMA with vigour and panache, which Willink would never have done. He too made significant concessions but his ferocious public rows with the BMA dominated the headlines, while his concessions attracted much less notice. This worked hugely to Bevan’s advantage. As his perceptive biographer, the leading historian Dr John Campbell, has observed,
“it was politically useful to Bevan that the BMA made such a fuss. It seems clear that Bevan privately welcomed, if he did not positively encourage, the BMA’s help in making the NHS appear a more socialist measure than it really was”.
There was not a great deal in Bevan’s plans that the Tories found wholly objectionable; after all, they shared the same objectives. But Bevan, consummate party politician that he was, exploited the Tories’ decision to oppose the complete nationalisation of hospitals. He relished blackening their name as the enemies of a great national reform. It was on the evening before the NHS came into operation that he made his notorious speech denouncing them as “lower than vermin”.
One of the great tragedies, perhaps, of the fierce partisan wrangling that took place over the structure of the NHS is that no one thought about its cost, even in Whitehall. Finance was not discussed as the legislation went through Parliament. As a result of this omission, politicians of both parties would be plunged into recurrent funding crises over the next 70 years. Bevan’s achievement was prodigious. Nevertheless, as John Campbell has pointed out,
“it must be said that too much can be claimed for him, and in Labour mythology often is”.
There was wide cross-party support for the NHS at its inception, just as there is today on its 70th birthday. It is perhaps a time for remembering Sir Henry Willink, as well as the great Nye Bevan.
Baroness Donaghy (Lab)
I thank my noble friend Lord Darzi for initiating this debate and I thank Nye Bevan for his towering achievement in setting up the NHS against concerted opposition—a miracle for those who had no money.
We still expect the NHS to cure all our social ills while tackling permanent supply and demand challenges. Government-imposed changes in legislation, reorganisation and financial stop/start policies make it difficult to plan for the long term and apply consistent recruitment and training policies.
If there is a chronic shortage of doctors, we import them. The Royal College of Physicians says that we are currently training only half the number of doctors required by 2030 and the cap on medical school places means that we reject half of all eligible applicants— 770 of them with at least three straight grade A’s at A-level. While I am not trying to correlate the possession of three A-levels with suitability, we should be training more in the UK. Instead, 700 rejected medical student applicants a year are studying to be doctors in the eight English-language medical institutions set up in former eastern bloc countries. This is crazy, and it is the responsibility of the Government. The recent announcement of more places is too little, too late.
The NHS cannot solve all our social ills. We do not have a proper social care system, and that has an immediate impact on hospital beds. Our GP system has been weakened to the extent that many patients do not have a hope of seeing their local doctor when they need to. There were 1 million hospital visits last year because of drug or alcohol usage. The human cost of obesity is appalling, but so is the cost to the health service, which has to pay for larger stretchers, beds and mortuary places.
It is vital that we improve transparency and accountability in our NHS. The Government abolished the independent review panels in 2004 and the recently established Healthcare Safety Investigation Branch plans to cover only 30 cases a year. Will the Minister say how the Government intend to invest in independent reviews, deal with complaints and protect whistleblowers?
The advances in medicine in the past 70 years are almost beyond belief. Some of the potential breakthroughs are exciting. One drug is being made from the strain of cannabis grown legally under Home Office licence. It has a high concentration of anti-convulsant and very low content of THC, the psychoactive compound. If approved, it could help up to 5,000 people with epilepsy. Research has shown that metformin, an anti-diabetes pill, also cuts the number of heart attacks, strokes and heart failures. Researchers call that repurposing.
Finally, I thank the BBC and ITV for their coverage of the 70th birthday of the NHS and for all the programmes that have been enjoyable, historical and absorbing. They have been inspiring and have made me realise that any future attacks on the health service will be met by an army of fierce defenders, all of whom have a story to tell.
Baroness Masham of Ilton (CB)
My Lords, I was in this Chamber when the noble Lord, Lord Darzi, then Minister of Health, saved the life of a noble Lord who collapsed in the debate. I congratulate him on all his wonderful and inspiring work. I declare an interest, as the National Health Service saved my life when I broke my back in 1958.
I celebrate the 70 years of the NHS, but I feel that safety in medicine should be the top priority. Without good communication and leadership, the patient can be left in limbo. Last week, I spent two-and-a-half days in St Thomas’ Hospital with an infection. It brought home to me the hugeness of the NHS and the pressure that it is under. The nurses I met were all agency nurses, and I understood their reasons for that, but I never saw a sister, so answers were not forthcoming. I left wondering what Florence Nightingale would have thought. There were some charming young doctors. One of them told me she had had problems since Brexit and was thinking of leaving. This is tragic when they are so badly needed. The Government need to work very hard on providing a competent NHS workforce across the UK, with good communication between hospitals and the community.
When injuries were expected from Normandy, a specialised spinal unit for the military was set up at Stoke Mandeville Hospital. In 1948 when the National Health Service was born, civilians with spinal injuries were admitted, and having specialised treatment and rehabilitation free at the point of need made all the difference for them. Stoke Mandeville is also celebrating the 70th anniversary of the paraplegic games this year. They were founded by Sir Ludwig Guttmann, who said that sport helped to rehabilitate patients. The games became the Paralympics of today. I cannot stress enough the importance of specialised treatment centres for many rare conditions. Their specialised teams of staff and drugs can save and extend life.
Our NHS must find watertight systems to safeguard patients and protect whistleblowers who may suspect and expose dangerous procedures. Safety is of the utmost importance. The duty of candour should become part of our health and social care culture.
Baroness Finn (Con)
My Lords, I thank the noble Lord, Lord Darzi, for introducing so beautifully this important debate. In an age where some view suggestions of NHS reform as heretical, I welcome the opportunity to put down ideological swords and approach the NHS and the issue of social care with the clarity of debate that our healthcare system so desperately needs.
Lots of people, including my family and close friends, rightly testify to the wonderful care that they have received from the NHS. I do not yet have grandchildren and congratulate the noble Lord, Lord Winston, and my noble friend Lady Morris on their recent arrivals, but St Mary’s in Paddington looked after me very well when I had both my children on the NHS, so I understand the emotional attachment that we have to the noble ideal of the NHS and the numerous examples of superlative care experienced.
However, although we are often told that the NHS is the envy of the world, it is not the envy of the developed world. The UK healthcare system consistently receives mediocre rankings in international reports. Even the Commonwealth Fund report ranked us last but one for healthcare outcomes. We need outcome-driven improvements to our National Health Service, as those matter most to patients.
There have been and will be many important contributions today from those with direct experience of the NHS. I shall therefore limit myself to three short observations. We must invest in early diagnosis. The UK has lower cancer survival rates than comparable health systems. The cost of late diagnosis can be up to four times that of early diagnosis, which in turn dramatically improves the chance of cure and survival.
Secondly, we need to help to transform a culture in the NHS that can be resistant to innovation. Without this, reform will prove ineffective. Healthcare professionals must absolutely be able to speak up for the benefit of patients without the risk of victimisation. The national guardian, Dr Henrietta Hughes, is leading a positive culture change by publishing case reviews to support the proper treatment of whistleblowers. Our remarkable NHS staff are our greatest asset and a rich source of knowledge. They must be empowered to identify concerns and provide solutions.
Finally, we must have a proper debate about the funding of the NHS. It is simply wrong to perpetuate the myth that any alternative to the current system is a malicious attempt at privatisation. It is not a binary choice. We all agree that healthcare in this country should be universally accessible. This was the original and great gift when the NHS was created. Although every developed economy now provides its citizens with universal access to healthcare, none has copied the UK model. Other healthcare systems—in Germany, the Netherlands and Switzerland—offer feasible alternatives that deliver not only better value for money but better outcomes for patients. We know that the NHS needs more money, but we should not presume to know how to get it.
I welcome the proposal of a cross-party commission, but if we seek a sustainable future, we must keep an open mind, fairly evaluate alternative regimes and resist the narrow dogma that hampers rather than protects the NHS.
Baroness Emerton (CB)
My Lords, I, too, congratulate the noble Lord, Lord Darzi, on opening the debate and thank him for being such a breath of fresh air, as he always is when he speaks in this House. I also thank the right reverend Prelate the Bishop of Carlisle for his words. It reminds me to confess my qualifications in the register as a retired nurse and midwife who started 65 years ago. I started in 1946 as a volunteer in the order of St John as a cadet, and learned the basics of life-saving and care. I have always been grateful for that background and the privilege that I had as a registered nurse.
In one of my jobs, as the youngest member of a consensus management team, I was asked to close two large hospitals and move mentally handicapped patients into the community. The first hospital had 1,500 patients and the second had 1,200 patients. It was my job to find a team that would work with me, with the money coming from the health service. I learned a tremendous amount about social services, working with two county councils and five London districts. It taught me one very large lesson: we have tremendous barriers that have to be broken down when we are concerned with delivering care. It is not a question of care in hospital and care in the community being different; we are looking at the whole person and their whole life. One thing I hoped, as I travelled through this task of 10 years, was that we were on the verge of reaching where we are today: considering bringing together health and social care.
I have always valued that experience, because I learned three things. One was that we needed the money, but that it needed to be spent cost-effectively and that we had to look at the way in which people were trained for this new model of care. The second was the high quality of care, which was different from that in an institution. The last was the culture in which people were cared for. I hope that, as a result of today’s debate and all that we have heard from the Government, we will be able to move forward, get rid of the barriers between health and social care and become one caring service.
Lord Colwyn (Con)
My Lords, I welcome the debate of the noble Lord, Lord Darzi. I must also declare my 40 years in the NHS and that I am a fellow of the British Dental Association.
In 1948, the nation’s dental health was in a worse state than that of defeated and occupied Germany; decay and gum disease were rife and more than three-quarters of the adult population had complete dentures. The creation of the NHS meant that, for the very first time, dental care was free at the point of use and the demand was overwhelming. By late 1948, more than 80% of practising dentists had signed up to work in the NHS and, in the first nine months of its existence, NHS dentists provided over 33 million artificial teeth, performed 4.5 million extractions and put in 4.2 million fillings. By 1951, the NHS started running out of money and so charges for dentures were introduced—the first charges of any kind for NHS treatment. This controversial move caused much debate and led to the resignation of Aneurin Bevan. Charges for other types of dental treatment soon followed and, to this day, dentistry remains the only part of the NHS that is not free at the point of use.
NHS dentistry today looks very different from the way it did 70 years ago. Modern technology means that dentistry today is relatively pain free compared with the dentistry of the past. Our nation’s oral health continues to improve and most of us keep at least some of our own teeth past the age of 85. Satisfaction with NHS dentistry is at a record high. Despite an estimated 10 million adults in the UK reporting dental anxiety and 6 million experiencing dental phobia, 85% of patients rate their NHS dental experience as positive.
We cannot, however, afford to be complacent. Although oral health on average is steadily improving for the general population, there are still unacceptable variations in outcomes, depending on where you live. Almost half of five-year-old children living in places such as Pendle, Rochdale or Burnley have tooth decay, but a mere 5% are affected in Waverley or Guildford. Tooth decay remains the leading reason for hospital admissions among young children, despite being almost entirely preventable—a scandal in 21st-century Britain. Increasingly, there are also problems with access to NHS dentistry in many areas. A recent BBC investigation revealed that only 52% of dental practices were able to accept new NHS patients. Almost half of all adults in England—a total of 21 million people—have not seen an NHS dentist for over two years.
The reasons for that can be traced back to two main problems: the lack of funding and a failed dental contract. NHS dentistry has been chronically underfunded in recent years. Nominal spending on dental services per capita fell from £41 in 2013 to £36 in 2017. This drop is even greater if we take into consideration inflation and the rising cost of dental materials. At the same time, patient charges in England have increased at an unprecedented pace—a 5% rise each year for the past three years. Data shows clearly that this fee makes many people delay going to the dentist until the problem has escalated, ultimately requiring more expensive treatment.
The second reason for problems with dental access and rising inequalities in England is the way that dentistry is commissioned. The failed NHS dental contract effectively sets quotas on the number of patients a dentist is able to see on the NHS.
Baroness Manzoor
I am so sorry. We are running late and have to go to the next speaker.
Lord Colwyn
I have only one more sentence. It has led to such low morale in the workforce that 58% of dentists are looking to leave the NHS in the next five years.
Lord Parekh (Lab)
My Lords, I am prepared to loan the noble Lord a second of my time.
I thank and congratulate my noble friend Lord Darzi on introducing this debate so beautifully. Having only three and a half minutes to talk about the NHS, I shall simply say that the NHS is a product of its time. That is very important to bear in mind, because the fact that it was born in 1947-48 penetrates its inspirational principles as well as its structure.
On the division between healthcare and social care, healthcare is free at the point of delivery, whereas social care is means tested, and that binary division is itself a product of its time and was introduced into the structure. There is also a distinction between physical and mental health. When the National Health Service was created, it should have meant the national physical and mental health service, but it tended to mean physical health. Mental health was added later and has enjoyed a Cinderella status; it has not enjoyed parity of esteem in the National Health Service.
My first point is that these various strands that the NHS has inherited have to be integrated, but the question is about how you do that when they are moving in different directions. We need to integrate but in a manner that respects the differences between the strands.
The second way in which the NHS has historicity is in the role of the GP. The GP began as a family doctor—an old tradition in this country—but he is now a gatekeeper. There is a division between the GP and the hospital, and that division also affects the relationship between the GP and his patients.
The third important feature of the NHS that is worth noting is that it began as a highly centralised institution. Those were the days of centralisation, with everything done from the centre. Now, there is an increasing realisation that that is not the way to deal with many of the problems, because problems are localised and so are the solutions. How do we move from a centralised to a decentralised structure? It is not just a question of decentralising an already centralised structure; it is a question of designing it from below and asking fundamental questions.
Here, I want to emphasise the important distinction between the way in which the NHS was conceived, based on excellent principles, and the way in which it has developed certain flaws. Some flaws are adventitious; others are structural, and the structural flaws need to be addressed very carefully—the fact that many of our doctors leave the NHS and leave the country rather than stay here; the fact that there is low morale; and the fact that hospitals are structured in such a way that the management takes over and the doctors count for very little. Those are some of the flaws. Therefore, while we celebrate the achievements of the NHS, we will celebrate them more sincerely and honourably if we are also alert to the weaknesses that it has developed.
When we talk about what we should do for the next 70 years, I simply urge a note of caution. Given the way we have tried to change it over the years, if we can get it right for the next 20 years, I shall be more than happy. Due to the way in which mental and physical health problems are distinguished and new insights into medicine and human health appear, there will be new questions, new divisions and new ways of organising our hospitals. In the light of that, let us think of the next 20 years, rather than the next 70.
Lord Dykes (CB)
My Lords, it is fitting and symbolic that the debate was opened by three of the foremost medical experts in this House. We thank the noble Lord, Lord Darzi, for initiating the debate. He was followed by the noble Lord, Lord Ribeiro, and the noble Lord, Lord Winston, who, although not a surgeon himself, is a great expert on his own subject in the medical field. We thank them for their remarks. I must give a strong word of thanks to the noble Lord, Lord Darzi, for his inspiring introduction. He covered a lot of ground and dealt with a lot of things. I agree with his implication—possibly it was even stronger than that and was a full expression—that we can all be proud and sentimental about the amazing National Health Service and what it has achieved but, at the same time, call for modernisation, efficiency and so on. I hope and pray, however, that we will avoid yet another upheaval of the administrative structures, which would drive people mad. That all comes together, and there is no sense of shame in saying that this taxpayer-funded service should receive more funds in the future. The period of austerity from this Government has been very painful for the National Health Service and we need to get over that now.
The noble Lord, Lord Darzi, mentioned his connection with the Royal Marsden. In 2003, for very sad family reasons, I had occasion to experience the Royal Marsden Hospital and its superb and wonderful treatment of people facing cancer. To a lay man like me, an example such as that remains in your memory for ever. I have always tried to avoid private healthcare, although I suppose that on occasion there is an emergency or one needs something quickly and therefore has to agree to a date being fixed if the NHS asks you to wait a bit longer. However, the service provided by the NHS is superlative. Even private medical companies often use its facilities and equipment because they do not have the same range of skills, equipment and expertise.
I commend the very good briefing note by the Library. It reminded us that the cost of the NHS as a percentage of GDP is similar to the EU average and very similar therefore to other leading countries. The cost of private healthcare is much more expensive for self-evident reasons, and I do not think it can ever match the efficiency of the NHS, despite it being funded in the way that it is. It is an amazing achievement.
I conclude not by trying to be clever for its own facile reason but by genuinely linking the dangers of Brexit with the National Health Service. Although there is no obvious connection at all between them, I was very grateful to the noble Lord, Lord Kinnock, for his letter to the Guardian today referring to these problems. He talked about the degradation of the physical economy and GDP as a result of the falling size of the economy already because of Brexit—it has already started and it is going to get worse if Brexit is to occur—and the departure of nurses and doctors from this country back to where they came from or elsewhere because they fear there will not be a positive future for them if we are not members of the EU. He quite rightly concludes by saying:
“Of the 52% who voted leave, few, if any, voted to sabotage the NHS”.
I am sure that is right. Therefore, that must be yet another collection of reasons why we have to think about the future of the NHS but also the future of the country.
Baroness Verma (Con)
My Lords, I am delighted to speak in this debate celebrating the 70th anniversary of the National Health Service. I join all noble Lords in congratulating the noble Lord, Lord Darzi, on opening the debate. The NHS is proudly the envy of the world but, with the increase in population and the discovery of new illnesses and diseases over time, we need a fresh way of looking at how it will function in the next 70 years. In saying this, I would like to speak about a part of the health service that is often seen as a separate arm but really should be an integrated and well-bedded key component of the delivery of care that the NHS must provide.
I declare an interest as a provider of adult social care, through a business I started 18 years ago. Since that time, we have seen huge changes both to the National Health Service and to social care. In my opinion, we should see them as two parts of the same ecosystem. Instead, they have had to fight for budgets and space within the political debate.
There seems to be a huge deficit in the understanding of how social care is delivered and how well funded the social care system should be to support the NHS. Every day, we hear politicians saying how much they love the NHS. It does not matter from which part of the political spectrum they come, but this mantra never includes the words that they also love social care. Until we have a radical change in our thinking about social care, understanding that it is part and parcel of the delivery of support in the health systems, the burdens on the health service will continue to increase and the funding of social care will continue to decrease.
An easy example to illustrate this is that, if you suffer from cancer, you would expect the health service to provide medical care and support to you free. Why then should someone who has dementia not have the same support at the point of need, just because they are being cared for in a residential setting? It is unjust to pit one type of illness against another, and it needs to be addressed, if we are to be a community that values justice and respect for everyone. With age come new challenges of illness specific to growing older. Does that mean that because we want people to live in their own homes we ignore their needs?
Social care is not just for the elderly; it also supports those with disabilities across the whole age spectrum, so it is high time to rethink how our health service and social care work are made to work as one. Social care has always been the poor relative of our healthcare systems yet, as we become more and more dependent on treating people at home, there is a large recognition that we are fast running short of adequately trained care workers to support people in their communities. The fact that funding for social care is delivered through local authorities and is never ring-fenced means that often any extra funding from government may be used for other immediate pressures faced by local authorities. That cannot be right.
If adequate resources were put into providing people with access to well-trained and better paid care workers, it would have an immediate and huge positive financial impact on the NHS, in terms of improved exercise, dietary plans and mental well-being. How does the input of social care providers get integrated into Ministers’ wider thinking about policy? I urge the Minister not to call just on the work of clinical commissioning groups. We know that there are huge gaps in social care provision; trying to find people to work in the social care sector is getting ever harder. How does the Minister feel we are going to fill the gaps of doctors, nurses, therapists, cleaners and carers once we leave the EU? The NHS cannot change for the sake of change; the Government must understand that you cannot fix a problem unless you fully understand what all the solutions are.
Lord Brooke of Alverthorpe (Lab)
My Lords, I am grateful to my noble friend Lord Darzi for a towering speech, made with spirit and committed to the fundamentals of the health service. We are extremely grateful to him. I express my gratitude to all who work in the NHS for all the outstanding work that they continue to do, often in difficult circumstances. I wear no badge today, but I have a kind of badge on my head, as I am wearing an NHS bandage from treatment I had this week. I shall be going to my doctor’s surgery tomorrow morning.
It is all part of my life. I was born before the health service was created, but I have had two near misses with my life. When I was 55, I had bowel cancer and was saved by the Royal Marsden. I was quite close to death, and here I am, 20 years on and still enjoying a fruitful life, for which I am eternally grateful to the health service and the people who work in it.
I shall take a different approach from anyone else. I have a different concern about the extent to which the public and I are responsible for the care of the NHS and how we deal with it. People can take it for granted in many instances and, as a consequence, the health service suffers. We do not get efficiency and effectiveness from it because of that—people not turning up for appointments and so on. It is important to continue to look at what we as individuals can do to make the health service even healthier.
I have suggested, and raised previously with the Minister, that one way in which we might bring about a change in attitude is to know what the cost of our health services is; after all, there is not much that we get in life whose cost we do not know, but that is not so with the health service.
The Government do not like this idea because they say that it might discourage people from taking up services. That is questionable. I have suggested in turn that those who would like to know the cost should be told, so that, if they feel gratitude to the NHS, they could make a charitable contribution towards a fund. It would be a fund that not just went towards the hospital where they had been treated or given the service but would be redirected to those areas in the country where we see the most ill health and the greatest deprivation in terms of health services.
The Minister has not responded very positively to these suggestions on previous occasions, so my appeal today is not to the Government but to my fellow Peers and to MPs: we should come together and, instead of words, words, words with nothing happening, we set up an all-party parliamentary group to look at how we might establish a charity that commemorated the 70 years of service that we have had from the NHS but in turn found ways of taking in contributions from those who were able to make them and wanted to express their gratitude for the services or operations that they had had from the NHS. I would certainly be prepared to do that. We would have a group of qualified people—maybe Peers or surgeons—who redirected the funds or gave advice on where they should go in the NHS. We should do it ourselves. If the Government will not do it, this is a source of considerable money among the public at large to which the NHS fails to respond. There is great feeling for the service. I believe that people would make bequests or offerings after they had had operations. It is time that we took advantage of what is there for us. I hope the Minister will respond that when he replies.
Baroness Watkins of Tavistock (CB)
I thank the noble Lord, Lord Darzi of Denham, for introducing this debate and for his excellent speech. I also thank the noble Baroness, Lady Verma, whose eloquence on social care and the need for investment in it I wholeheartedly support. I declare my interests as in the register, most specifically as a mental health nurse of some 40 years’ standing.
There is a clear case for further integration of physical and mental health and community and social care provision if we are to meet the needs of our citizens and promote healthy living and, where necessary, treatment intervention. I am involved with the social movement Nursing Now, working with policymakers and senior nurses from several continents.
In Africa, a phrase is used: “Health is made in the home and communities and hospitals are for repairs”. We need to adopt this approach in our communities to serve our citizens as cost-effectively as is feasible. We are celebrating our investment in 70 years of the NHS, which has resulted in people living longer and healthier lives. However, this has brought the challenges associated with many older people having several complex health and social needs, a situation that was not fully anticipated in 1948. The challenges facing our young people in terms of mental problems and the increasing prevalence of non-communicable diseases associated with lifestyle are resulting in higher demand for healthcare intervention.
The demands on the NHS will continue to rise unless we focus on public health policies that encourage citizens to become more responsible for their own health. With the access we all now have to digital data, why should we not be more responsible for our own health records and monitor our responses to exercise, diet and medication? If our citizens are to be more accountable for their own health and well-being, they will still need health education, support and guidance to do so. Families need help in the early years of their children’s lives through effective health visitor interventions combined, where necessary, with structured support from social services and mental health interventions for families with experience of anxiety, depression or severe and enduring mental health conditions. Yet we know that these services are under considerable strain and that, even when sufficient resources are available, families and individual citizens complain that different workers often fail to work collegiately to provide coherent packages of care. If community-based health and social services were better integrated, it would be easier for individual providers of care to deliver appropriate services, as indicated in some of the vanguard sites. This also includes successfully reducing delayed transfers of care.
I have two further suggestions that I would like the Minister to consider. First, there should be a move towards more clinical treatments for people in their own homes, care homes and nursing homes. In Spain, it is not uncommon for a person with pneumonia to be treated with intravenous fluids and antibiotics in a nursing home, and even occasionally in their own home, without the need for hospital admission. Serious consideration of more simple treatments being given outside acute hospitals needs to be undertaken. This would reduce the need for more hospital beds and allow a redistribution of resources towards community-based interventions.
Secondly, all healthcare workers should be expected to be proficient in coronary pulmonary resuscitation and physical first aid. The APPG recently heard, when reviewing progress against the five-year mental health strategy, that there is a real need to increase training in acute in-patient first aid across society. I very much hope that we will do this.
Baroness Harding of Winscombe (Con)
My Lords, I begin by declaring my interest as the chair of NHS Improvement and thanking the noble Lord, Lord Darzi—my esteemed colleague on the NHS Improvement board—for his masterful introduction to the debate. After listening to various noble Lords who have contributed their whole working lives to the NHS, and thinking about the more than 5,000 NHS staff members who are still working there after more than 40 years’ service, I have to say that I feel like a bit of an impostor in this debate, having all of seven months’ experience of working in the NHS, in NHS Improvement. I have tried to hold three things in my head as an employee of the NHS who is still learning. The first is that the NHS is undoubtedly the best health service in the world. In the round, taking everything into account, it is the fairest service and is definitely the most efficient one. As my noble friend Lady Finn said, clearly there is room for improvement, but I would contend that it is one of the most cherished institutions in the land. While we look at how to improve it, it is really important to remember, in everything that we say and do, how brilliant it is.
Secondly, it could be so much better. The variation in outcomes for patients across the country is just not acceptable. You only have to be a patient or the carer of a patient for 10 minutes to see how money is being wasted. We could be more efficient and at the same time deliver better outcomes. Thirdly, we are all living longer. Technology is enabling us to live well for longer, which is a good thing. It is a problem of success, not failure, but it is none the less a problem that must be faced, and in reality it is one that will require more money for the health and social care system.
What should we do? Many noble Lords have talked about the important need to integrate care in the health and social care system: the governance, the structures and the money flows. I would like to focus on the people: the 1.7 million people across the United Kingdom who are working for the NHS. They are our greatest asset and it is really important that we help and support them by preparing them for the future. If we are to deliver integrated services, we will need to drive considerable change in the NHS. That will include organisational change, process change and technology change. Change is hard for everyone, however clever and experienced they are. It means that the NHS needs to improve significantly the way in which we manage and lead.
Just as there is variation in clinical practice and operational processes, there is enormous variation in management and leadership capability in the NHS. I have met some of the very best managers I have ever seen in any walk of life in the last seven months, but unfortunately our NHS staff tell us very clearly in their staff survey that that is not uniformly the case. I have been shocked by the results of the NHS staff survey, first by how small a percentage of staff actually fill it in—50% to 60% filling it in is deemed as a huge success in the NHS. Best practice in industry would tell you that 80% to 90% just filling the survey in is a measure of real engagement. The percentage of people who say that they have been witness to or have experienced bullying is terrifying. On average it is 24% of staff and at the worst trust it is 41%. All this points to a management and leadership culture that needs to change to prepare us for the future.
We need to instil a consistently just and learning culture. We need to root out bullying and replace it with honest and open management, and to encourage much more flexible working and the greater diversity in leadership styles that reflect the way our society is changing. These are not “nice to dos”; these are the essential building blocks if we are to transform the NHS to meet the challenges that various of your Lordships have set out. I know that it is tempting at this national political level to focus on money, organisational structures, regulatory levers and command and control, but it is the people of the NHS who have made it the national treasure that it is today. Focusing a bit more on supporting and developing the people in the NHS, their culture and ways of working will be the essential ingredient for success in the next 70 years.
Lord Faulkner of Worcester (Lab)
My Lords, like every other speaker I am delighted to congratulate my noble friend Lord Darzi on the brilliant way that he introduced the debate. I thank him for the hundreds—probably thousands—of lives he has saved during his very distinguished career as a surgeon. My contribution will focus on why treating tobacco dependency must be embedded throughout the plan that NHS England has committed to delivering in return for the additional £20 billion it has been allocated. The evidence for this is set out in a major new report published just last week by the Royal College of Physicians. I declare an interest as a long-standing officer of the All-Party Group on Smoking and Health.
Helping smokers quit is not just about prevention. It improves treatment outcomes and helps poorer people in particular to live longer. Take lung cancer. Currently, at diagnosis one-third of lung cancer patients still smoke and their average life expectancy is nearly doubled if they quit, yet fewer than a quarter get advice to quit from their GP and only 13% are prescribed stop smoking medications. Helping to quit smoking costs hundreds of pounds and has a similar impact on life expectancy as the latest lung cancer drugs, which cost tens of thousands of pounds per course of treatment. So why are lung cancer patients not being given the help to quit that they need?
Tobacco dependency treatment is cheap and saves the NHS money. The RCP has calculated that if all smokers were provided with help to quit the NHS could save £60 million annually in hospital admission costs and A&E attendances alone from year one onwards. This includes the cost of the treatment, which is only £182 per quitter. By freeing up beds and saving money, it would ensure the additional £20 billion can be used more cost effectively.
We need only look to Greater Manchester, where the CURE programme will start to deliver treatment for all smokers from September, to see the potential gains. Manchester has almost 53,000 hospital admissions of active smokers every year. Smokers are admitted with cancer, heart disease, mental health conditions, HIV/AIDS—the list goes on. It has been calculated that providing patients with tobacco dependency treatment will save the equivalent of 250 additional beds per day. This will help to tackle the winter bed crisis in Manchester. Smokers are five times more likely to have micro-biologically confirmed influenza. When combined with other smoking-related respiratory diseases, such as chronic obstructive pulmonary disease, this can lead to their admission to hospital at the worst time of the year.
Supporting smokers to quit will also deliver improved maternity outcomes. Every year, maternal smoking in the UK causes 5,000 miscarriages, 300 perinatal deaths and 2,200 premature births. Younger mothers in disadvantaged circumstances who have never worked are more likely to smoke throughout their pregnancy. These are the immediate savings; the benefits in the longer term are even greater, as current smoking costs hospitals almost £1 billion a year, most of which is avoidable.
It is not that smokers do not want to quit—over 60% say that they do—but our hospitals are not providing the help that the most addicted need if they are to succeed. Will the Minister ensure that NHS England takes into account the evidence and recommendations set out in the recent RCP report on treating tobacco dependency as it develops the new plan for the NHS?
Lord Hennessy of Nympsfield (CB)
I add my congratulations to the noble Lord, Lord Darzi, on an inspiring opening speech.
In the life of a nation, there occur a few ripe, golden days—the kind of day that you want to “bite to the core”, to borrow a line from the poet Edward Thomas. Undoubtedly, 5 July 1948 was such a day. The British state came as close as it ever has to institutionalising altruism when the Attlee Government created the National Health Service. As we have heard already, it was shaped by that man of genius and brilliant word power, Aneurin Bevan, who the noble Lord, Lord Morgan, once aptly described as “an artist in the use of power”. Its core principle was the pooling of human risk and financial resource—that the National Health Service should be taxpayer funded and free at the point of delivery—which has been sustained by every Government since.
The National Health Service was, and is, one of those national banners around which my generation rallied, as it has served us since we were in our cradles. No doubt we will still laud it as it eases us towards our graves. Talking about the welfare state in 1948, Nye Bevan said to his Parliamentary Private Secretary, Barbara Castle, who recorded it for me in a television interview 20 years ago:
“Barbara, if you want to know what all this is about, look in the perambulators”.
Given our average age, that encompasses many of us in the Chamber—we very fortunate children of the early post-war period.
Let us go back to vesting day 70 years ago. More anxiety was lifted off more shoulders on 5 July 1948 than possibly any other single day in British history. It was an extraordinary day. The creation of the NHS was a declaration of great national purpose. Achieving it over seven decades has been freighted from the beginning by the core problem that we have heard much about this afternoon: demand has always outrun the funds available to meet it. We now have a golden chance to tackle that. Let us rally once again around the banner of the NHS, the flag that we have rallied around all our lives.
In this vexing era, when we torture ourselves daily with our differences over Brexit, perhaps here at last is a consensus that is there for the taking. I dearly hope that it will be taken, shaped by that rigorous, realistic national debate of which the noble Lord, Lord Winston, spoke so forcefully. We owe it to the founders of 1948 and the generations who have devoted their professional lives to this extraordinary institution over the past 70 years. This is an hour for seizing.
Baroness Gardner of Parkes (Con)
My Lords, I emphasise that I have worked in the health service for well over 60 years, but there is still such a lot to learn about it. Something important to have come out of today’s debate is that we should look at a lot of things again.
I know that the noble Lord, Lord Mawson, spoke about doing away with health centres. I do not agree at all with that. As a dentist, I found that health centres were a very effective way of giving treatment to children. Parents, especially now that you have to pay for dental examinations, no longer take their children to their own dentist twice a year, which is what used to be the practice. Now, children are lucky if they are seen before they are in pain, which is a most awful reason for anyone to go for treatment: you are automatically very worried and unhappy from the start.
I congratulate the noble Lord, Lord Darzi, on securing this debate. It is very far-reaching and should be considered in detail. Certainly we should use more of those health centres, as we did in the past, and more respite care, or cottage hospital-type recovery after hospital. We are using a very expensive facility to keep people in hospital during their recovery when they would probably much rather be in slightly more homely surroundings. Of course, they would have to be adequate for the treatment that they were recovering from, but all these things are possible if enough thought is applied to them: that is what I believe should happen.
In these couple of minutes which is all we have, I pay tribute to the very many dentists and doctors—huge numbers of them—who came from the Commonwealth in the early days of the National Health Service. In Australia, where I graduated, anyone who had been in the forces was allowed to go to university if they had enough qualifications. As a result, 150 dentists a year qualified in Sydney and there was no work for them; they were just out digging the roads or working on the Snowy River scheme; anything to be earning a crust. Then someone discovered that, yes, there were jobs over here. The first ones came and they passed the word on to all the others. In the early years, in this country, the big thing was that people looked to full clearance of teeth at the age of 21 as the desirable situation in dentistry, which was unbelievable. When we arrived, children’s teeth were in a terrible condition.
Commonwealth dentists, in particular from Australia, New Zealand and South Africa, all of whom had a higher degree, which was acceptable here, did a huge amount. We almost got the situation completely under control, but now it is as bad as it ever was. In Manchester, we find that children cannot have ordinary operations under general anaesthetic because every slot is taken with clearance of baby teeth: that is just hard to believe. I have almost run out of time so I will not go on further, but I think we have a lot to think about and a lot to aim at. I want to pay tribute also to Lord Pitt, David Pitt, who did a marvellous amount here, coming from quite a different part of the Commonwealth. He was a hospital patient in the hospital I was chairman of and was so undemanding it was just hard to believe. There is still a great deal for us to do.
Baroness Gale (Lab)
My Lords, I thank my noble friend Lord Darzi for bringing this important debate before us today and for the wonderful story he told, making us realise how much we must cherish this precious asset we have. The improvement in women’s health since 1948 has been absolutely amazing. I have the time to mention just three measures: the oral contraceptive pill, the Abortion Act 1967, and the improvements in the treatment of breast cancer.
The pill was introduced in the UK and became available on the NHS in 1961, but it was for married women only at that time. That all changed in 1974, when family planning clinics could prescribe single women the pill: it was a very a controversial decision. Now it is taken by 3.5 million women in Britain between the ages of 16 and 49. It gave women, for the first time, the freedom to control their own fertility and it was a great liberation for them. It avoided unwanted pregnancies and a woman could decide when to have children. It proved to be a great advantage in so many ways. Women could now plan their lives, in terms of their education and their job development, and could choose when and if they wished to get married. It changed our society and allowed women the freedom that women of earlier generations could not have dreamt of; that was all because of the National Health Service.
The Abortion Act 1967 allowed women to have safe, legal abortions under the NHS and did away with the illegal back-street abortions that many desperate women turned to because there was no alternative. In 1990 the time limits were lowered from 28 weeks to 24 weeks for most cases because medical technology had advanced sufficiently to justify the change. The Act does not apply to Northern Ireland, but at the last general election the Labour Party manifesto said:
“Labour will continue to ensure a woman’s right to choose a safe, legal abortion—and we will work with the Assembly to extend that right to women in Northern Ireland”.
We are committed to ensuring that women in Northern Ireland will have the same rights as women in the rest of the UK. I trust the Government are equally committed.
Screening was introduced for breast cancer in 1988 in the United Kingdom and now women aged 50 to 70 are offered tests every three years; older women can ask for one. More than 55,000 women are diagnosed with breast cancer each year in the United Kingdom, but the good news is that more women than ever are surviving breast cancer thanks to better awareness, better screening and better treatments. Around five out of six women diagnosed in the United Kingdom today will be alive in five years’ time, compared with three out of six 40 years ago. The charity Breast Cancer Now has an ambition that by 2050 everyone who develops breast cancer will live. It believes that its research will allow it to achieve its ambition to stop breast cancer taking lives. Combined with the work that the National Health Service is carrying out in research and medical advancements, I think this is possible.
Everyone in this country can give thanks to the National Health Service, especially for the advancements in women’s health. I give thanks to the National Health Service for bringing about such a great improvement in women’s health.
Lord Bird (CB)
I am really pleased to be talking in this debate about the National Health Service. I started life in St Mary’s Hospital. My mother, a lovely Irish lady, said that I was the most difficult birth because instead of it taking 10 Woodbines to birth me, it took 20. I should not really be here: I should be dead, because I come from poverty. I am in the House of Lords because of poverty, to try to dismantle poverty and to prevent poverty happening.
I do not want to sound like Mark Antony at Caesar’s funeral, but talking about the National Health Service raises a number of questions for me. One is: are we talking about the National Health Service or the “I will get you back to health” service? My problem is that when I look around, I look at the big, ugly sun that sets and rises over all of us, which is poverty. According to a friend of mine who worked at St Thomas’ Hospital, 60% to 70% of the people the NHS has to deal with come from poverty. Because they come from poverty, they present their poverty in many ways and one of the big ways is in their health.
I will quote two human beings. One, John Newton, is the director of Public Health England, who makes the point that 40% of all illnesses that present in hospitals and the National Health Service are preventable and 23% of deaths need never have happened.
I have a quotation from 1944, from the MP for Rochdale, Dr Hyacinth Morgan, who said:
“The whole question of social medicine, with the questions of good milk supply, prevention of disease, good food and nutrition, good housing, good recreational facilities, prevention of mental disability in its early stages—all this has been left out of the White Paper”.—[Official Report, Commons, 16/3/1944; col. 494.]
Looking at the National Health Service over the past 70 years, I would say that it is an absolutely wonderful invention that has saved many members of my family. I have yet to use it, but, when it does come along, I am sure you will give me a brilliant send-off.
The point is that, unless we find a way, instead of spending 5% of the national health budget on prevention, to move it mainstream, we will always be worshipping at the altar of the accomplished fact. We will always be dealing with health rather than the terrible reality that exists behind it, which is the fact that we live in a poverty culture; we have poverty capitalism, where the poorest among us have to resort to the kind of food that can lead only to bad health. Until we get rid of poverty capitalism, we are not really going anywhere, and we will be talking about more and more needs for the National Health Service. The National Health Service will become even bigger unless we tackle the elephant in the room, which is poverty.
Lord Bhattacharyya (Lab)
My Lords, I thank my noble friend, Lord Darzi, for securing this debate, which has demonstrated how important our National Health Service is to the lives of so many in this House. I was very proud of the IPPR report—I was a long-standing trustee of the IPPR. I am an engineer; I am not a doctor. I design cars. However, I am married to a midwife, as well as the proud father of both a dietician and a recently qualified junior doctor; I have taken a great interest in this area. On that note, I should draw attention to my interests in the register.
This debate asks how the National Health Service can serve our nation in future. I want to raise two examples of how digital technology can improve our national health. Today the National Health Service is far from being a digital organisation. In fact, it is the world’s largest purchaser of fax machines. However, current digital resources can be used to improve future NHS services. In radiology, the NHS has held images and reports for a decade: millions of X-rays, scans and diagnoses. At the same time, radiologists face ever greater time pressure. Only seconds can be given to reviewing each new X-ray. This leads to outsourcing to expensive tele-radiology firms, which then make a lot of mistakes that cause a lot of errors.
We have an opportunity to build artificial intelligence systems that use the NHS’s historical data to identify which new X-rays radiologists should examine first. It is a form of digital triage. At my place we are developing such a system for chest X-rays. In future, the same principles could be applied to CT scans and MRIs.
Data anonymisation is essential, but, as my very good friend Dame Julie Moore of Queen Elizabeth Hospital in Birmingham, with which we are co-operating, said, no patients have refused consent to her trust collecting outpatient data.
Another way we can improve the use of current data by the NHS is with patients who have multiple chronic conditions. These cases are so complex that the causes of worsening symptoms may not be apparent even to experienced healthcare professionals. Furthermore, when multiple treatments are prescribed the patient can be overwhelmed. These patients do not need to present to a GP or an A&E as often as they do. A digital care planning programme could intelligently understand how treatments interact, prompt patients to medicate correctly and allow healthcare professionals to monitor patients remotely. Such technology and devices are available now. This would reduce the pressure on front-line NHS providers and provide better care to patients at home or in social care.
We desperately need to support innovation if the NHS is to succeed for the next 70 years. Sadly, as the Science and Technology Committee report on life sciences has said, the structure of the NHS stifles innovation. Innovation is a topic I am familiar with. We have been innovating in British manufacturing industry for a long time. We need to transform the way the NHS applies new technologies. To achieve this we need strong leadership on innovation in the National Health Service. Innovation is simply essential and is very easy to use. However it is important that we have the skills base to use it.
Baroness Finlay of Llandaff (CB)
My Lords, the noble Lord, Lord Darzi, in his superb opening speech, reminded us that we must not forget what the alternatives to the NHS look like, when whole tranches of the population cannot pay for care. As Bevan said:
“The field in which the claims of individual commercialism come into most immediate conflict with reputable notions of social values is that of health”.
It is said that you cannot know where you are going unless you know where you have come from. Our roots go back far. Lady Beatrice Webb led the 1909 minority report of the Royal Commission on the Poor Law, which called for a unified medical service. Beveridge, himself a researcher for the minority report, recognised the influence of that on himself. Then Bevan, in an inspired political appointment, took on the medical resisters, and we all celebrate the benefit from their defeat.
My interests go back more than four and a half decades, working fully in the NHS. I am grateful to all the patients I have looked after, who have taught me so much and enriched my life. It is a two-way process, and it is has been an honour and privilege to work with them.
In Bevan’s book In Place of Fear, he wrote:
“Preventable pain is a blot on any society. Much sickness and often permanent disability arise from a failure to take early action”.
By embracing artificial intelligence, we now have amazing opportunities for early action: we can decrease error, diagnose sepsis, acute kidney injury and melanomas, use CT and MRI to diagnose cancers, and so much more. The horizons are expanding before us. In my own cancer centre we are using virtual reality to help patients understand what is happening to them. Yesterday, at the Bevan Commission international conference—I declare my interest as a commissioner—artificial intelligence was seen as key to reducing error but was not expected to replace clinical roles in the next 10 years.
The latest paper from the Bevan Commission stresses the need for social support and social change. This week, Vaughan Gething, the Minister in the Welsh Assembly, has announced plans for Wales to be the first “compassionate country”. Across society, we must all take responsibility. Loneliness is a killer.
We must recognise the unique value in each individual and harvest it, recognising that adverse childhood experiences result in poor physical and mental health in adulthood, and take responsibility. For these children, the most important factor in their future is a stable adult in their lives.
Social care prevents some problems and delays others. It does not substitute for, or replace, life-saving technology or highly complex interventions when we need them.
We need a huge shift in controlling data. Patients should be able to access all their data. The OpenNotes trial found that 99% of patients and 75% of doctors want to continue with open access.
Bevan said that we would be in a state of constant change, and we are. We must look forward. We must not carry on squeezing until the pips squeak, but we must value care, science and vocation in our staff, so that in 70 years’ time we can meet the greatest need without the threat of somehow having to find money to pay—perhaps even millions of pounds if it is life-saving.
Lord Naseby (Con)
My Lords, it is an honour for all of us in this place to speak in this debate on the 70th year of the NHS. We owe a great thanks to the noble Lord, Lord Darzi, for showing the initiative. We also owe him a thank you for when he was the Minister on the Benches for the Government, over a number of years, because he certainly got a grip of things when he was there. I also pay tribute to my noble friend sitting on the Front Bench, as it is a long time since we have had a Conservative Member sitting there who has tried really hard to get a grip of the issue.
I am a marketing man by profession and I am looking at the things on which we need action on a practical basis. I start with the GPs; I am married to a retired one. It is not working at GP level today, on the whole. I exempt the GP practice where I am a patient at Greensands in Potton, which is pretty good, but it is not working because there are not enough GPs. There are also not enough district nurses. Those are the two key areas. Just look at the figures for district nurses. The graph has gone down for the last X number of years, certainly the last 10 years. We have to double the number of district nurses, because they are the people who visit patients at home and keep them out of hospital and the GPs’ surgeries. That is point number one.
Secondly, my wife was a full-time GP and she looked after me and three children in our constituency, and all the rest. Initially, she had a small practice and she built up to a very large practice in Bedfordshire. There were night calls and weekend calls. One of the doctors did minor surgery and it worked well. None of that happens today. Why do we not have minor surgery from our GPs? That would relieve our hospitals a little. Why do we not have more GP hub units like the one in Biggleswade today, which works at weekends? It is looked after not by doctors who are running their normal practices, but other doctors do the work and that unit works well.
Thirdly, we need to look at the number of doctors. We have about 50% of what we need. I hope nobody thinks that I am biased, but there is something wrong with the gender balance. Nearly 60% of the medical school intake is female now. The net result, as ladies across the medical profession will know, is that 5% never work, 80% work half-time and about 15% work full-time. Against that background we need two women for every man, so that is a challenge. Moreover, my son works as an Army doctor and he had it in his contract to work for five years. In Singapore, if you take a medical degree you have to work full-time for five years. Not surprisingly, if you leave early you have to pay back the money that has been spent on you.
As a further point, in Bedfordshire there is the Luton and Dunstable Hospital. It has a unit where, when you arrive, they assess you and you go either to its GP unit or to A&E. Seventy per cent go to the GP unit. That is the situation.
Finally, on payments, I am fed up with looking in my surgery at the number of people who do not turn up. Somehow, we have to find an answer to that. Personally, I think we should trial a £10 fee for those who fail to turn up.
Lord Dubs (Lab)
My Lords, I congratulate my noble friend Lord Darzi on initiating the debate and on his speech.
Exactly 70 years ago today, I was a patient in Stockport Infirmary. I was quite ill. In those days, when the consultant did his rounds it was like God visiting, with a team of doctors, matron and so and, if I remember rightly, one was supposed either to stand to attention if one was well enough or lie to attention if one was not. I was lying to attention. The consultant came by and I said, “Just a minute. I have a question to ask you”. One did not ask consultants questions like that, so he turned around and said, “What is it?”, and I said, “Are we having a party today?”. He said, “What for?”, and I said, “The hospital’s ours. Isn’t it terrific?”. He walked on. I was the only child in the ward and the other patients asked me what was going on. I explained and I think I got a few Labour supporters out of that.
I should declare that, more recently, I was a member of an area health authority and, even more recently, I was a member of a mental health trust, and I found it a privilege to serve on both those bodies.
I welcome the Government’s recent announcement of a bit of an increase, although it is only a standstill increase and does not increase the resources going into the health service. For all the criticism of the health service, I think we get fantastically good value for money out of it. If we look at the percentage of GDP spent on health, we compare extremely well with many other countries. Most of the major European countries spend more of their GDP on health than we do, and the Americans are way ahead. The trouble is that we get all this on the cheap. It is to the detriment of the health service that it is too easy for the Government to turn off the financial tap for reasons of austerity, and there are no safeguards to protect the health service against a Government’s short-term need to save money. My noble friend Lord Winston made that point earlier. I believe the value for money is incredibly good.
I hope that the Government will tackle the problem of social care. It is all too clear that so much bed-blocking takes place and that the health service would benefit if people could be moved out of hospital when they are well enough into their home with support or into other forms of residential support. It is to the detriment of the health service that we allow this to continue. We have to tackle it.
At a local level, Charing Cross Hospital in West London, which is much loved and much appreciated, is still under threat. There has been a big campaign to save it. The local health authorities wanted to close it down. At the moment, it is still there, at least until 2021. In the meantime, the Government have added £7 million to the A&E services, which are very important, but there is no point in putting money into A&E in the short term unless we have some assurance that the hospital will continue. The trouble is that we have to get out of the position in which the Government can too easily cut off the money so we do not have any long-term assurance about the health service.
Finally, I believe this most sincerely: the British people would accept an increase in taxation in order to fund the health service more securely. They would accept that, provided it was hypothecated for the health service. I know the Treasury does not like that, but I believe that if the people of Britain were told that more money from taxation would be used directly for health and social care, they would accept that.
Lord Warner (CB)
My Lords, I, too, add my congratulations to the noble Lord, Lord Darzi, on his excellent speech and his constructive IPPR report. He and I have both had a go at reforming the NHS, and I think we can at least congratulate ourselves on not creating a mess on the scale of the Health and Social Care Act 2012, from which the NHS still suffers.
The NHS has been a key part of our welfare state and a great piece of communal risk pooling and social cohesion. It has survived some difficult years with its funding veering around from famine to feast and back again. It has become like David Attenborough and Judi Dench: a national treasure. However, the trouble with national treasures is that they can end up like Danny Boyle at the 2012 Olympics, engaging in a fantasy view of something that badly needs to change but gets frozen in the national psyche.
The NHS and its staff are tired in part because its business model and operations badly need a major overhaul. The NHS still operates the organisational silos created 70 years ago. It has not integrated its own services very well, let alone integrated with social care. It is still largely a sickness service rather than a health service. Public health, mental health and adult social care remain Cinderella services financially, while the acute hospitals remain the financial preoccupation of most elected politicians. The patient base of the NHS now lives much longer than in 1948, with a set of comorbidities that come largely from lifestyle choices, but the service delivery system has changed little, despite countless reorganisations. It certainly does not deliver consistent quality across the country.
The way services are delivered needs to change radically and swiftly. Simply giving giving the NHS shedloads of new money without a credible and enforceable long-term reform plan would be a waste of taxpayers’ money. The NHS England long-term plan promised for this autumn needs to provide for a radical shake-up of the way in which services are delivered outside hospital, the way in which staff are trained, treated and deployed, and the way in which technology and regulatory change are to be implemented. There needs to be a sweeping away of the 2012 governance and accountability arrangements. This plan must lock funding into reformed services outside hospitals and will need regular parliamentary scrutiny on its delivery. It must also be supported by a new, credible and sustainable funding system for adult social care, which remains in a parlous state both financially and through the growing collapse of the publicly funded social care provider market. Unless the Government show a greater sense of urgency about a new funding system for social care, they are setting up the NHS to fail.
Let us be clear. There is no Brexit dividend for the NHS. The OBR forecasts show the UK economy flattening out, flatlining at about 1.5% growth a year after Brexit. This will make it very difficult to sustain a 3.4% real-terms annual increase for the NHS over a long period. So the NHS had better get on and reform itself quickly while the financial sun shines briefly for a moment.
Lord Astor of Hever (Con)
My Lords, I, too, congratulate the noble Lord, Lord Darzi. I was in the Chamber when he leapt across that Bench to save the life of a noble Lord who had had a heart attack, and a very impressive sight it was. I, too, have suffered a cardiac arrest and I received life-saving care from two wonderful paramedics from the South East Coast Ambulance Service.
My personal experience, not in a way that I would have chosen, was of the NHS at its very best. Everything at every stage, from the moment the cool-headed handler took the 999 call, the paramedics who got my heart going, the surgery, to the kindnesses and the professional aftercare that I received in East Surrey Hospital, could not be faulted. I was honoured when the hospital asked me to open its wonderful new cardio wing and meet the staff. It was an emotional event for me to stand in front of the very people who had saved my life, giving me an opportunity to join this debate today.
I declare an interest, in that my sister was a state registered nurse, my brother-in-law is a retired senior surgeon with the NHS and my niece is a junior doctor training in infectious diseases. She is extremely proud to be part of the NHS and very optimistic for the future.
While we bask in the reflected glory of all that the NHS has achieved in the past 70 years, I agree with the noble Lord, Lord Winston, that we must be realistic. We need to remember the winter pressures and looming targets that put the NHS under immeasurable pressure and result in less than optimal patient care.
At this late stage of the debate, I will touch on just one challenge facing the NHS, which has been mentioned by many noble Lords: creating a sustainable workforce moving forward, particularly as we rely so heavily on European and overseas staff. Since we voted to leave the EU, there has been a dramatic reduction in the number of staff coming from Europe. Although immigration restrictions have been lifted, it is going to take time to recruit staff. The NHS must be able to offer a long-term future, or why would they come? The focus should be on making medicine and nursing attractive again and developing a long-term plan that meets workforce challenges. There is much bridge-building to do after last year’s junior doctors’ strikes if the NHS is to keep them once they have completed their training. Junior doctors welcome Jeremy Hunt’s pledge for more medical school places, but there are ongoing concerns about low morale and rota gaps in the workforce causing significant issues with retention of staff. Worryingly, junior doctors are leaving not only the NHS but the profession altogether.
With regard to nurses, this is the last year that those in training are entitled to receive a bursary and will not have to pay university fees. They will then have to pay £29,000, plus living costs, for a three-year period. This means that most nursing graduates will leave university with debts of around £54,000. I would be interested to hear whether the Minister is concerned that this issue will have a negative impact on nurses’ recruitment.
Lord Murphy of Torfaen (Lab)
My Lords, I was born in 1948, five months after the maternity unit in which I was born was taken over by the National Health Service—that was 70 years ago today and we are debating that anniversary.
Yesterday, in the House of Commons, my successor as Member of Parliament for Torfaen, Nick Thomas-Symonds, gave a lecture on Nye Bevan—on whom he has written a wonderful biography—and the National Health Service. In it, he referred to the Tredegar Medical Aid Society, which was an embryonic version of the National Health Service, based as it was on the spirit of community and solidarity of the people in south Wales. It was Nye’s intention then, as he put it, to “Tredegarise” the rest of the United Kingdom, which he successfully did. We have heard—particularly of course in my noble friend’s brilliant opening speech—of the three principles of that service: it is free at the point of use; it is financed from central government; and everybody is eligible to use it. In Nye’s words, he believed that it would,
“lift the shadow from millions of homes”.
Since Nye’s day, the NHS has of course been devolved. He was not too keen on devolution but I think that he might have changed his mind as the years have gone by. In Wales today, a country of 3 million people, we have 20 million patient contacts a year, 1 million seen in A&E, £7 billion spent on health and social services—in Wales, the two are put together—and 100,000 staff. It has been the fashion over the past few years for Prime Ministers, when they face criticism of the English health service, to say that the Welsh health service is not up to much. Far from it. In fact, it is an unfair comparison. The people of Wales worked mainly in coal, steel and heavy industry and, in consequence, there was a much greater need for health services than in parts of England. Nor was the comparison necessarily like for like because, as I said, health and social services in Wales are combined, which is not the case in England.
Over 90% of Welsh people are well satisfied with the National Health Service. More is spent per person on health in Wales than in England. Wales was the first of the home nations to ban smoking in public places, to ensure that parking in hospitals is free and to introduce free prescriptions. I certainly want to celebrate our National Health Service today by thanking all those 100,000 people who work in the health service in Wales and, of course, all those hundreds of thousands of others who work in the United Kingdom.
Finally, to quote Nye:
“Society becomes more wholesome, more serene, and spiritually healthier, if it knows that its citizens have at the back of their consciousness the knowledge that not only themselves, but all their fellows, have access, when ill, to the best that medical skill can deliver”.
Lord Selsdon (Con)
My Lords, I apologise for my delay in speaking but my mobility is not as great as I would have hoped. I made the mistake of being a wicket keeper for many years and was suddenly told that I needed a new knee, having found that I could not walk.
One thing about the NHS is that, when you do not know it, you do not know what to expect. The NHS gave me a new knee. Attractive girls came to drip-feed me every evening, and then I found that I could walk and almost run. Against that background, I find it quite intriguing that we now have the technology to deal with all forms of sports activities. I found that the first thing the NHS needed to get was a new knee, which had to be ordered from the United States. I wondered why we did not do new knees. The surgeon was American and the operation was done by the NHS in London, then I was told, “You can go home shortly”, but they were not sure that they could trust me. When I got home, I found that every day at six o’clock two ladies turned up to give me injections in my arms and so on in case anything went wrong. Then—lo and behold!—I found, with joy, that I could walk properly, and I have been able to do so almost ever since.
With that thought in mind, I turn to the difficulty of dealing with the authorities. You make a telephone call and, before you know it, you get into the bureaucracy of receiving pieces of paper requiring you to attend another hospital appointment. I have had nearly 10 hospital visits with people wanting to check me out—they found that I had lost weight. It was the care that I received from the NHS that impressed me, as well as the fact that I can walk again. I am extremely grateful to it for what it has done for me.
Baroness Jolly (LD)
My Lords, I join other noble Lords in thanking the noble Lord, Lord Darzi, for tabling this timely debate and for his excellent speech in kicking it off. It is one of those speeches that we will want to reread, and we will need to pick up a copy of Hansard on Monday.
These Benches are proud that on this day 70 years ago the Leader in your Lordships’ House was Lord Beveridge, author of the report implemented by the Attlee Government, thus creating the NHS and social care entitlement. So perhaps this is true co-production.
I start by noting the contribution to today’s NHS of all the staff who over the last 70 years have worked tirelessly, whether as clinicians, carers, cleaners or managers, and I pay tribute to the current employees too. But what would somebody from 1948 make of the NHS now? My father-in-law graduated from Leeds medical school in that year and was one of the first cohort of NHS doctors—and very proud he was too. He recalled that there was a handful of drugs that they could prescribe, and after their six years’ training they knew pretty well all the medicines that there were to know. Later, he ran a GP practice from his home. One room became the waiting room and another the surgery. The family recall syringes being sterilised on the kitchen stove. He and a partner set up a practice which grew and grew, and it still exists. Today, I think he would be delighted to see his practice offer patients the ability to book appointments online and order repeat prescriptions, but he might be rather bemused by the need for a practice Facebook page.
Today, the life expectancy for men is 77 and for women 81. Then, it was 66 and 71. I think several of us have been looking at different briefings with different numbers, but the numbers are in the right sort of order. No one quite appreciated the impact of the impending baby boom rippling through the population. Most of the residents in today’s care homes were born before the NHS came into existence, and unless we mend our lifestyles a large proportion of us will not live as long as our parents.
In the new NHS, public health and prevention was important. I remember queuing in the village hall for cod liver oil, orange juice and polio jabs, and once at school we had nit inspections, eye and hearing tests, and TB jabs. Public health looks very different today—gone are the nit inspections—but local authorities have public health responsibility all over again. They look at health as a determinant in housing, social care and wider community services.
Prior to the NHS, the first port of call often was the high-street chemist for a chat with the pharmacist, who would be able to recommend the right remedy. This conversation was free, and a visit to the GP was out of reach for many. Now, too many of us visit our GPs expecting a prescription when we have a cough, cold or sore throat. We are unaware that we can get better with the help and advice of the pharmacist. If this was to be adopted as the first port of call by us all, our GPs would have time to deal with the people who are really poorly.
There cannot be a sustainable NHS without sustainable adult social care. Adequately funding social care would deliver benefits for local communities and savings for the public purse. For example, funding an expansion in social care capacity would alleviate NHS pressures and therefore enable more people to be discharged quickly and safely from hospital. We all have friends and relatives who, whether due to age, ill health or dementia, have found themselves in need of social care. The continued underfunding of social care affects us all. It is making it increasingly challenging for local authorities to fulfil their legal duties under the Care Act, leaving the ambitions of some aspects of the legislation at risk. Equally concerning is that, by 2025, another 350,000 people will need high levels of social care from councils. As the ADASS budget survey highlights, moving towards prevention and early intervention is one of the most important savings areas identified by councils. However, as budgets reduce, it becomes harder for councils to manage the tension between prioritising statutory duties towards those with the greatest needs and investing in services that will prevent and reduce future needs.
The current move towards integrated care organisations is welcome, but success will depend on strong leadership and a willingness of both health and care to co-operate, to share a budget and to involve patients, those in care and carers, and the voluntary sector in system design. As mentioned by the noble Baroness, Lady Morris of Bolton, the initiative currently under way in Greater Manchester, where 10 councils came together to deliver health and care services locally, has much potential. We await evidence of success and impact on the health community. In Cornwall, my part of the world, for the last year or so the local council has been working closely with the CCG to achieve the same end but on a much smaller scale and in a rural setting. However, where any services are devolved, we are also clear that national standards need to remain and that accountability will be key. As a quick note to the noble Baroness, Lady Gardner of Parkes, Cornwall still has all its community hospitals and they are used as step-up and step-down units. The challenge posed by the increased localisation of services is the risk of a postcode lottery in both availability and standards. Those local councils where there was the greatest need have low-rated housing, and any dividend from raising council tax is not enough to plug a gap.
Almost two years ago now, my right honourable friend Norman Lamb commissioned a group of experts from within the sector to look at the vexed issue of funding the NHS and social care. Among the recommendations were an annual rise in real-terms funding for the NHS in England in line with long-term growth. For the next five years, we believe that a 2% rise per year is a realistic figure. This should be matched by equivalent increases in funding for the devolved nations under the Barnett formula. A further recommendation was to set up an independent OBR for health to make recommendations to government about the funding required for a three-year cycle.
Recently, the noble Lord, Lord Patel, who sadly is not in his place, chaired a Select Committee of the House on the long-term sustainability of the NHS and adult social care. This was a look at the current system by a group of Peers with long experience of working in the NHS, government and social care. Their report was full of positive recommendations—it read like a critical friend’s review of an organisation in need of change. It took the Government some time to bring it to the House for debate; let us hope it takes less time to implement some of the recommendations.
Artificial intelligence, biosimilars, genomic medicine and robotic surgery would have been unimaginable to those doctors in 1948, but who knows what the next 70 years will bring. In many areas, we are on the cusp of system failure yet, in others, of huge system innovation. Organisations needing support should be encouraged, not punished. The Government need to be bold in their decisions and announcements in November. The Green Paper on social Care and its funding should be person-centred, encourage creative solutions and provide the necessary funding to deliver appropriate support for the NHS and for its stable future.
Lord Hunt of Kings Heath (Lab)
My Lords, it is an honour for me to wind up for the Opposition in this debate. Because I am going to refer to NHS management, I remind the House of my presidency of the Institute of Healthcare Management, the Health Care Supply Association and the Hospital Caterers Association.
I start by expressing my thanks to my noble friend Lord Darzi for his magisterial opening speech. The vision that he set out was profound and inspiring in urging us to revitalise quality as the organising principle of health and care, investing in health and not just healthcare and investing in the talent of our staff as well as tilting, as he said, towards technology to create a digital-first health and care system. My noble friend Lord Bhattacharyya really very much reinforced that. He also said something very important—that he saw the NHS as the expression of a moral principle that no one should be denied healthcare because of their means. I could not help thinking that Nye Bevan would have approved. In his essay “In Place of Fear”, he uncannily anticipated the wretched outcome of the Government’s attempt to marketise the NHS when he said:
“Preventive medicine, which is merely another way of saying health by collective action, builds up a system of social habits that constitute an indispensable part of what we mean by civilization. In this sphere values which are in essence Socialist challenge and win victory after victory against the assertions and practice of the competitive society”.
Amen to that, my Lords.
The intervention from the noble Lord, Lord Lexden, in response to the noble Lord, Lord Pendry, about the history of the Conservative Party and the NHS was very interesting. However, at the end of the day, the party voted 21 times in that Bill on the formation of the NHS. I say to the noble Lord, Lord Lexden, that I think Bevan was entirely right to believe that Henry Willink’s plan to leave the voluntary and local authority hospitals in their existing ownership would have led to a much patchier and second-rate service.
The remarkable speech of the noble Lord, Lord Hennessy, recalled the profoundly positive impact of the lifting of the financial fear of the consequence of illness. It is right to celebrate that—but I am with noble Lords who want a sober analysis of the NHS and the challenges that it faces. The BBC should be commended on commissioning a report on the relative strengths and weaknesses of the NHS from the Health Foundation, the IFS, the King’s Fund and the Nuffield Trust. You could not look to better institutes than that for it—and it was sober. It said that, although the NHS leads the world in terms of equity of access and ensuring that people do not suffer financial hardship and performs well in managing long-term conditions, such as diabetes and kidney disease, and is relatively efficient compared to other systems, outcomes are its Achilles heel.
Although the NHS is closing the gap in a number of areas, we still lag behind in saving lives when treating many of the leading causes of death, including several types of cancer, heart attacks and stroke. It is comparatively poorly resourced. I do not think that having average GDP spend for the whole of Europe is actually anything to be proud of, given that we are the fifth or sixth-wealthiest country in the world. We are poorly resourced. We have markedly fewer doctors and nurses than comparable health systems. We have the lowest number of hospital beds, CT scanners and MRI scanners. We are one of the slowest nations to take up new medicines and new developments. We have a long way to go. Although international comparisons are always subject to the caveat of being a partial picture, it is clear that we enter the eighth decade in uncertain health.
Funding is a clear issue. Of course we welcome the injection of £20 billion for the NHS over the next five years, but it is not the long-term solution that my noble friend Lord Winston and other noble Lords have called for. It is nowhere the near the 4% per year that most organisations reckon should be the base funding. Of course, that money does not cover public health, training, capital spending and social care.
All my noble friends have talked about the need for a fundamental change in social care. The Green Paper is awaited in the autumn. All I have to say to the Government is that they had better deliver on this. Frankly, there is no chance of integrated care in the way they talk about unless we deal fundamentally with the problem of the current means test and find a way to cap the cost for individuals having to pay for their own care. Nothing else will deliver the kind of integrated care that we need.
Noble Lords have talked to an extent about other forms of funding. The noble Baroness, Lady Finn, implied that we need to look at those. I repeat what my noble friend Lord Darzi said: by far the most efficient, dignified and lowest-cost way is to create a universal service free at the point of need. As he said, it is a fundamental error of logic to say that because something is unaffordable we should move to something more expensive and, indeed, more inefficient.
Noble Lords have raised many issues. On mental health and public health, I echo their points, but I want to end on the workforce. The NHS faces some pretty fundamental issues in relation to its workforce. One in nine nursing posts is unfilled and the number of unfilled vacancies among GPs is soaring, as is that of young doctors qualifying, leaving the NHS and going abroad. Morale is probably the most serious issue that we face. My noble friend Lord Parekh suggested, I think, that front-line workers were inhibited by managers. In my role as president of the Institute of Healthcare Management, I want to defend the role of managers in the health service, but I accept, as my noble friend Lord Darzi said in his report, that poor leadership and demotivated staff are a precursor of system failure. That echoes one of the most incisive reports on NHS leadership and management, by the noble Lord, Lord Rose, when asked to look at this in 2014. The Secretary of State did not like the response, so nothing happened because of it, but it talked about the,
“level and pace of change”,
being “unsustainably high”, with,
“the administrative, bureaucratic and regulatory burden fast becoming insupportable … The NHS has committed to a vast range of changes”,
but,
“there is insufficient management and leadership capability to deal effectively with the scale of challenges”—
that echoed what the noble Baroness, Lady Harding, said. However, I have to say to her that it is no good just blaming managers. There is a combination of overbearing regulators, an absence of leadership from Ministers, the complexity of the 2012 Act, the tightness of funding, the risk aversion and the widely prevalent bullying culture—which starts with the Secretary of State, with his insistence on sacking chief executives willy-nilly. It is no good the Secretary of State talking about bullying in the health service until he looks at his own behaviour and how he and the regulators relate to people in the service, because no one locally will believe in this unless the people they are answerable to change their own behaviour.
We come now to the issue of the disastrous Health and Social Care Act 2012. It was the most ill-conceived piece of legislation that the health service has ever seen. As was said earlier in the debate, in an extraordinary speech made on 18 June, the Prime Minister basically said that the Act was a disaster. She referred to clinical commissioning groups having to negotiate 200 different legal contracts with other parts of the NHS. That is ludicrous, costly and totally ineffective. I say to the Minister that the Government should consider bringing forward a Bill to get rid of the current bureaucracy and the enforced marketisation contained in the 2012 Act.
No one can pretend that the future is going to be easy for the NHS and social care. The challenges are formidable and the solutions are tough. Moreover, the demands will not go away. However, the NHS is resilient. It has brilliant people and it enjoys huge support. My noble friend Lord Darzi said that in 30 years’ time, he hopes to see the centenary of the NHS. I am pretty confident that he will and that the people of this country will demand nothing less.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord O’Shaughnessy) (Con)
My Lords, I join other noble Lords in congratulating the noble Lord, Lord Darzi, on an inspiring and typically incisive speech, and thank him for his leadership both in this House and in the NHS. We are truly grateful to him. I also want to thank all noble Lords for their contributions to the debate. Most of all, I want to thank the millions of people who work in the NHS and social care services because they look after us so expertly every day. Noble Lords have shared their personal experiences and we all have our own reasons to be thankful for the service. For me, it was the care that we received before, during and after the very complicated birth of our third child. It was simply world class. I am pleased to say to the noble Lord, Lord Winston—as I think I have before—that the birth was at the Queen Charlotte’s and Chelsea Hospital. All my children were born there and I am delighted to hear that his grandchild has been delivered successfully there too.
I want to take up the spirit channelled by the noble Lords, Lord Winston and Lord Hennessy, about consensus. As I said at Question Time this morning, it is important to recognise that politicians from all the main parties had founding roles in the NHS. The noble Baroness, Lady Jolly, talked about the role of William Beveridge. My noble friend Lord Lexden reminded us of the White Paper published in 1944 proposed by the Conservative Health Minister Henry Willink, and of course many noble Lords reminded us about the founding of the NHS by that very special and particular politician, Nye Bevan, on the principles—as the noble Lord, Lord Murphy, pointed out—of the Tredegar Medical Aid Society. It is also important to acknowledge the point made by the right reverend Prelate the Bishop of Carlisle that it was also an expression of Christian purpose, something that Nye Bevan himself acknowledged. As the noble Lord, Lord Hennessy, said, it was the nationalisation of altruism. It is also, as the noble Lord, Lord Bird, reminded us, part of our national effort to end poverty; that is what is at stake. My view, which I shared with noble Lords during a debate initiated by the late and much-missed Baroness Jowell at the beginning of this year, is that the NHS’s enduring popularity is not just because of the service it delivers but because of the many noble ideas it represents: reassurance, compassion, service to others and hope.
In delivering world-class care over the past 70 years, the NHS has changed enormously. The budget has gone up by 10 times. As my noble friend Lady Harding pointed out, the NHS is rated as the best health system in the world. The reasons for that were set out compellingly by the noble Lord, Lord Darzi, in his speech. Over those seven decades, the NHS has led the world in a great many aspects of healthcare. In 1958, the NHS introduced the first public vaccination programme; in 1968, the first heart transplant in Britain and the 10th in the world; in 1978, Louise Brown was born, the first baby ever successfully conceived by IVF; in 1986, we had the world’s first major government-sponsored national AIDS health campaign; and, as the noble Baroness, Lady Gale, reminded us, in 1988 the national breast cancer screening programme was set up. In 1994, the NHS established the first national organ donation register, while in 2002, doctors at Great Ormond Street carried out the world’s first successful gene therapy. Moreover, just last year, the NHS introduced the world’s first trial of 3D-printed bionic hands for children. That is an extraordinary and ongoing record of success.
But while the NHS has an enviable record, as noble Lords pointed out, of delivering world-class care, we know that it can get better. I read with great interest the excellent review of the NHS from the noble Lord, Lord Darzi, which he wrote with my noble friend Lord Prior of Brampton. I also note the improvements in care quality and safety that he says have been achieved since his original review in 2008. But we are all agreed—as my noble friend Lady Finn, the noble Lord, Lord Hunt, and others have pointed out—that there are great challenges ahead. Our cancer survival rates are not good enough, not least because of late diagnosis. Mental health services, which I will return to, still lag behind. Poverty is still a factor in outcomes. Too many babies and their mothers are lost at birth, and our growing and ageing population presents us with entirely new pressures.
There is an urgent need to address these challenges, as we all agree, and to provide an NHS fit for the future. It is for precisely that reason that the Government have announced that there is to be a five-year funding settlement for the NHS of, on average, 3.4% a year. The noble Baroness, Lady Tyler, the noble Lord, Lord Hunt, and others have talked about whether that is enough and mentioned 4%. It is important to point out, as Simon Stevens has done, that the NHS has got more productive than the UK economy overall. When you add in those productivity gains that is a big increase in the effective budget. Over the timeframe of that five-year funding settlement that will take us up to the level of France in terms of the percentage of GDP spent.
Noble Lords have talked about leadership. It is an act of leadership by the Prime Minister and my right honourable friends the Secretary of State and the Chancellor. It provides us with a unique opportunity for the NHS to develop a long-term plan to transform the service and, as the noble Baroness, Lady Donaghy, and the noble Lords, Lord Dubs and Lord Warner, pointed out, to avoid the feast-and-famine approach that has bedevilled us.
Several noble Lords have pointed out that only the NHS is included in this plan. That is quite right at this point in time. Nevertheless, it is important to point out that public health and social care were specifically mentioned in the settlement insomuch as, whatever the funding settlement for those in the spending review, it will not put extra pressure on NHS services. We will of course deal with those in the spending review next year.
The NHS plan will be led and developed by clinicians and patients. I promise the right reverend Prelate the Bishop of Carlisle that it will be inclusive. It is based on six key principles: focusing on the prevention of ill health; significantly improving access to good mental health; driving forward the integration of health and social care; spreading best practice and eliminating variations; embracing the opportunities of technology; and building the workforce we need for the future. Contrary to the suspicions of the noble Lord, Lord Dubs, Simon Stevens, the head of the NHS, has said himself that, together with his plan, the money will enable us to do more than just stand still. We have before us the opportunity—as the noble Lord, Lord Hennessy, said, the golden opportunity—to transform health and social care in the years ahead.
The right reverend Prelate the Bishop of Carlisle pointed out quite rightly that, first and foremost, we must continue to focus on prevention, not least because, as the noble Baroness, Lady Jolly, pointed out, unhealthy behaviours are associated with a significant number of early deaths in the UK. Each year there are around 80,000 deaths related to smoking, a point alluded to by the noble Lord, Lord Faulkner; 30,000 deaths related to obesity; and 7,000 deaths related to excessive alcohol consumption. This must change.
The noble Lord, Lord Faulkner, spoke powerfully about the pernicious impact of smoking. Our tobacco plan lays out an ambition to reduce smoking among adults in England to 12% or less. I confirm to the noble Lord that that aligns with the Royal College of Physicians’s proposals. We are making all NHS estates smoke-free by next year.
As noble Lords will know, to fight childhood obesity—a hot topic in this House—there are new taxes on sugary drinks, and we are helping children to exercise more and cutting sugar and calories. As we have shown in our most recent chapter, chapter 2, of the obesity plan, we are prepared to take radical steps to beat this epidemic. I am also grateful to my noble friends Lord Colwyn and Lady Gardner for pointing out the essential role that NHS dentistry has in delivering a truly preventive care service. However, we all agree that there is a need to go further. We want to help people to develop the right habits for healthy living. The noble Lords, Lord Hunt and Lord Brooke, my noble friend Lord Naseby and the noble Baronesses, Lady Finlay and Lady Watkins, all quite rightly said that we need to take more personal responsibility for our health, not just relying on it being delivered by others.
As we know, mental health problems affect people of all ages and all backgrounds. There is an unacceptable difference between the way that people with physical health and those with mental health problems are treated. We know that we have legislated for parity of esteem, but we have not yet delivered it. As a first step, this Government are investing more than ever in mental health services. We invested nearly £12 billion last year and aim to create 21,000 new posts by 2021 as part of the mental health workforce plan, with the first waiting time standards and an expansion of support for schools. In response to the question of the noble Baroness, Lady Tyler, on percentages, as long as less than 100% of those with mental illness do not receive the care that they need, we will not have succeeded. The challenge for the NHS as it develops its plan is how close we can get to that magic figure in the next 10 years.
Probably more than any topic that has been discussed today, integration is key to delivering the outcomes that we want. We have to break down barriers. As my right honourable friend the Prime Minister said, we have to deliver “integrated patient-focused care”. I am incredibly grateful to the noble Baroness, Lady Emerton, for sharing her experiences, although it is slightly depressing that we still face the same arguments about how to deliver truly integrated care.
My noble friend Lady Morris and the noble Baroness, Lady Watkins, talked about the fact that current health and social care services can be difficult to navigate, particularly for those who are frail, elderly or have multiple comorbidities. Increasingly, that is the typical NHS patient. We have made some progress, with the better care fund encouraging local health and care system leaders together. The noble Baroness, Lady Watkins, mentioned the vanguard areas, where we are making significant progress in reducing pressure on A&E. We are now giving the best-integrated local areas the chance to become integrated care systems, giving them more freedoms and the ability to join up systems in their area. Several noble Lords talked about Greater Manchester, which is indeed a shining example in this area. On the challenge from the noble Lord, Lord Parekh, we need to demonstrate that more areas are capable of leading that kind of work.
The noble Lords, Lord Warner and Lord Hunt, have deep concerns about the legislative framework and whether it hinders care today and will do so tomorrow. It is right to focus on the signal given by the Prime Minister to the NHS about wanting to heal the barriers to the provision of integrated care, legislative and otherwise, that are out there. That was a genuine and open offer. There is a desire to build consensus on this if consensus emerges on the need for change.
My noble friend Lord Naseby joined the noble Lord, Lord Darzi, the noble Baroness, Lady Watkins, and my noble friend Lady Gardner in saying that more care needs to be delivered closer to home. I absolutely agree with that idea of neighbourhood care. Having met the noble Lord, Lord Mawson, to talk about his work, I applaud him for leading that very local integration of care. I would absolutely recommend that noble Lords who are not aware of it investigate his work and find out more about it.
Quite rightly, many noble Lords talked about the future of social care. We know that there are funding needs. Over three years, about £9 billion of extra funding has gone into social care in the short term. Clearly, there is a need for a fundamental settlement. A Green Paper is coming, and it is a golden opportunity. We know that successive Governments have failed in this area. I hope that we can solve this, not just as one party but with all parties working together. The noble Lord, Lord Hunt, asked about the means test, the cap and floor. I can confirm that that will be in there. As my noble friend Lady Verma pointed out, this is not just about funding; the paper also has to address the many iniquities and inequalities that exist not only in the social care system but between the social care and NHS systems. Those words are very well taken.
As the noble Lord, Lord Hunt, pointed out, variation in care has been the NHS’s Achilles heel. The Care Quality Commission’s latest state of care report found substantial variation in care quality in and between services, in the same sector, between different sectors and geographically—and historically, between genders, as pointed out by the noble Baroness, Lady Gale. That is clearly unacceptable. As we would expect, the noble Lord, Lord Darzi, made a very profound recommendation in his IPPR report that we should,
“revitalise quality as the organising principle of health and care”.
We quite agree, as does my right honourable friend the Secretary of State, who has made quality—particularly patient safety—the leitmotif of his work in the health service.
That is one reason why we are funding the “getting it right first time” programme—I do not know how many noble Lords are aware of it, but I encourage those who are not to look at it—where data from front-line medics helps eliminate unwarranted variation and spread best practice. Since it began in 2016, GIRFT’s recommendations have helped trusts reduce the length of stay for hip and knee operations for the sportsmen of today that the noble Lord, Lord Selsdon, talked about, freeing up 50,000 beds a year and finding £50 million in savings over two years. That is just in one specialism, orthopaedics, although GIRFT is now looking at 35 different clinical specialities nationally. However, I take the point of the noble Baroness, Lady Masham, that with greater specialisation in services there is a need for greater transparency to prevent closed cultures. There are a number of programmes, however, as is often the case, aimed at reducing variation—GIRFT, RightCare, the Model Hospital, regional medicines optimisation committees—and one of the goals of the long-term plan must be to bring these efforts together into a single, co-ordinated approach to eliminate unwarranted variation.
The noble Lord, Lord Darzi, and others talked about tilting towards tech: I could not agree more. Despite being, as my former boss said of the then Chancellor, a slightly analogue politician in a digital age, noble Lords may know that I have become a passionate advocate for the unique opportunities of technology in the NHS. I quite agree with the noble Lord, Lord Bhattacharyya, and the noble Baroness, Lady Finlay, about the importance of patient data—giving them more control over their data to drive that technological change. It has to be recognised that the NHS, and the universities and life science companies that work with it, are wonderfully innovative. Being creative in coming up with new ideas is our great strength. Spreading those ideas throughout the NHS is often where we fall down, as my noble friend Lady Finn, and the noble Lords, Lord Bhattacharyya and Lord Hunt, pointed out. It is one of the reasons that I was so delighted last month to be able to appoint the noble Lord, Lord Darzi, as the new chair of Accelerated Access Collaborative—he may need to add that to his lengthy list of declarations—which brings together leaders from the NHS, industry and government to fast-track access to transformative medical innovations. We are expecting great things.
The noble Lord, Lord Winston, asked about academic health and science centres. They are very much in our thoughts as we work towards our improvement of the innovation landscape in the NHS. We have also commissioned Dr Eric Topol to lead an independent review of how advances in genomics, digital medicine, artificial intelligence and robotics can improve clinical staff skills, to make the most of those technologies. The noble Baroness, Lady Finlay, talked about the use of virtual reality in care and the noble Lord, Lord Bhattacharyya, talked about the use of AI in pathology and radiology. Those are just some of the areas in which we are making great advances: we could talk about genome sequencing or the new NHS app. There is an opportunity for the NHS to lead the global healthcare revolution in technology in the years ahead.
Finally, we all agree that the NHS is nothing without its wonderful people. We are absolutely committed to ensuring it has the staff it needs to meet increasing patient demand, both now and in the future. I agree with the noble Baroness, Lady Donaghy, when she pointed out that more of these should be recruited locally. I also agree with my noble friend Lord Naseby about the need for more GPs and district nurses. It is one of the reasons we announced a 25% increase in training places for doctors, nurses and midwives. I congratulate my noble friend Lady Morris, and more specifically the University of Bolton, for achieving that number one rating in nurse training. My noble friend Lord Astor spoke about the fact that not only are we increasing the number of doctors, but we are opening new medical schools in Sunderland, Lancashire, Canterbury, Lincoln and Chelmsford.
It is important to reflect on the point made by many noble Lords about the role that staff from outside the UK have played, not just in the founding of the National Health Service but in the National Health Service today, whether it is the Windrush generation, people from the Commonwealth or people from the European Union. We salute the work that they have done. We know there has been some anxiety around because of Brexit and it is important that we now have the settled status opportunity: the route is out there, it has been publicised and we have written out to the NHS and social care to make sure that our social care and healthcare workers can take advantage of that opportunity.
Later, alongside the long-term plan that we are publishing, there will be an integrated health and social care workforce strategy, making sure that we have the right number of staff, with the right skills and the right level of morale, to deliver the care of the future. My noble friend Lady Harding and the noble Lord, Lord Parekh, were on the money in pointing out the importance of leadership in actually changing some of the negative cultural problems that unfortunately persist.
To conclude, as we celebrate the NHS’s 70th birthday, we can look ahead to what the next 70 years might look like: powered by technological innovation, fuelled by intelligent uses of data and increasingly personalised. This future would be barely recognisable to the founders of the NHS in its speed of innovation, power to fight disease and ability to deliver care to people at the right place and time. But it is still a future where, I and the Government believe, the founding idea of the NHS—free at the point of need for everyone—remains its shining principle. This Government are committed to that future, as our five-year funding settlement has shown. After 70 successful years, the NHS’s own 10-year plan will set out the next part of its life-changing journey. I look forward, as all noble Lords do, to seeing what it brings.
Lord Darzi of Denham
My Lords, I have a few minutes to finish off. I thank everyone here for their amazing contributions on this very special day—the 70th anniversary of the NHS. The thoughts and ideas, although diverse, were all united in one thing: not just celebrating the past but designing the future. I particularly thank the noble Baroness, Lady Jolly, my noble friend Lord Hunt and the Minister. The noble Lord, Lord O’Shaughnessy, is a man of tremendous integrity and resolve. He addressed every speech. I know of his ability but also the talent he is surrounded with. We all wish him the best with his six-point plan.
I will end with one piece of advice: as we move into the future, we need to work with the patients and the public who are funding this, while remembering that the NHS staff whom we congratulated are people we would want to work with rather than do things to. We have learned that by experience and we look forward to the autumn and the plans that the Minister will bring back to this Chamber. I very much hope that all parties in this Chamber will support it. We have one chance to do this. I congratulate the Minister on making sure that we got the money—3.4%—which none of us was expecting. We need to spend that money wisely because there is a confidence issue out there with the taxpayer and the public. Again, I thank noble Lords for a wonderful debate.