Lord Hunt of Kings Heath
To move that this House takes note of the NHS Long Term Plan, published on 7 January, and the case for a fully funded, comprehensive and integrated health and care system which implements parity of esteem, preventative health and standards set out in the NHS Constitution.
Lord Hunt of Kings Heath (Lab)
My Lords, in opening this debate I declare my interests, particularly those relating to health, as listed in the register. The NHS gives extraordinary care to people in the United Kingdom. It enjoys huge popularity. Yet it is struggling. Austerity has taken its toll. We have seen a deterioration in services and the key access targets have not been met for many a month. Add in increased rationing of treatments, cuts to public health funding, inadequate mental health services and disinvestment in social care and it is hardly surprising that the NHS faces unprecedented pressure. This is what makes the NHS plan so important and why it is important we debate it today to try to turn this around.
I can say at once that much in the plan is welcome: the expansion of primary and community care; the drive for integrated care; the emphasis on clinical services for young people; and the identification of clinical services for cancer and cardiovascular disease, for example, where outcomes in this country lag behind many comparable countries. Welcome too is the acknowledgement of the role of carers, which appears a number of times in the plan. Particularly ambitious is the aim to transform services, using technology to provide many more online interventions and reduce patient visits to out-patient clinics by up to a third. The plan also hints at further centralisation of hospital services for major trauma, stroke and other critical illnesses, again to improve patient outcomes.
So the plan’s overall thrust is welcome as far as I am concerned, but my worry is that the Government have not learned from previous efforts to transform and integrate services. For a start, the plan is almost entirely focused on the National Health Service. It is a great pity that it was published in advance of the Green Paper on adult social care. It also shows scant recognition of the crucial role of local government, particularly in the current crisis in social care, yet the intended integration of health and care simply cannot happen without local authorities being full partners and some kind of long-term funding settlement for social care.
Similar challenges await the NHS, it seems. The plan promises increased investment in primary and community care, but where will it come from when acute hospital services are at full stretch and demand for services will inevitably grow? Although the plan is a sensible statement of intent, the question is: where is the beef to make it happen?
I start with funding. It is no surprise that the NHS is under funding pressure. A growing proportion of the population is aged 65 or over. We already have 2.9 million people with long-term multiple conditions. This is bound to grow over the next 10 to 20 years. It is always hoped that new technology will reduce costs, but the experience of health so far is that it tends to increase costs. If we add that to the current deficits among providers, the demographic challenge and the additional commitments given in the plan, there is a big bill to pay.
The report of the Lords Select Committee chaired by the noble Lord, Lord Patel, who cannot be here today, recommended that funding for the NHS should increase at least in line with GDP. We know that the consensus among health policy analysists is that we need 4% real-terms growth per year to meet these kinds of challenges. This is what the NHS received in patches, but on average, between 1948 and 2010. Since then it has flatlined at about 1% real-terms growth. Even the injection of an average of 3.4% over the next five years will not make this up.
According to the plan, the intention is for the NHS to return to financial balance. Productivity will increase, and the growth in the demand for care will be reduced through better integration and prevention. Overall, the plan presents this as a cohesive response to the funding crisis. All I would say is that that is a courageous offer from the NHS.
Alongside funding, the other big challenge is the workforce. We already have fewer doctors and nurses than any comparable country. This is likely to worsen in the near to medium term. The GMC—I declare an interest as a board member—points out that one in five doctors aged 45 to 54 are considering leaving the profession in the next three years. Even more worryingly, nearly a quarter of doctors in training and just over a fifth of trainees have informed the GMC that they feel burned out because of their working conditions and pressures. We know that other professions face similar challenges. We know too that we have a big problem with the largely low-paid social care workforce.
A big question to put the Minister is why the workforce implementation plan, which is some months away, was not published alongside the 10-year plan. What confidence can we have that the forthcoming spending review will provide the funding that, in the context of Brexit, is bound to be required for a huge increase in the number of training places? Also, why on earth are we having an NHS workforce plan? Why can we not have a health and social care workforce plan? The document preaches integration, but the Government have a wholly disintegrated approach, with no joint plans for money, the vision or the workforce. I say to the Minister: if the Government are serious about integration, for goodness’ sake start integrating your own efforts.
I will briefly touch on technology. I should again remind the House of my membership of the advisory board of Sweatco. The Secretary of State is putting a lot of effort into technology and the use of artificial intelligence. I support and welcome that. However, the report produced this week by the Academy of Medical Royal Colleges on some of the ethics involved in artificial intelligence is well worth reading. It makes the point that if technology is thought to help reduce demand on the health service, the Government might get a shock. As the academy points out, many of the technology approaches might actually encourage people to make greater use of health care, rather than being a sensible demand measure. I do not think the Secretary of State has quite got the hang of that yet, but he will need to if we really are to make the most of technology. The plan is lacking in detail on how performance and standards will be maintained, or how the impact of technology on patients, the workforce and cost-effectiveness will be assessed. We need to see that detail.
I refer noble Lords to my trusteeship of the Royal College of Ophthalmologists in saying that one example of something that works is the National Ophthalmology Database. It is a clear example of a large-scale audit that has improved the quality and safety of cataract surgery, reduced unwarranted variation and is making savings. Yet at the same time as we are being promised this great investment in technology, that database and others are in danger of being pulled because the department and NHS England are not making available the money to fund them in the future. I hope that the Minister might agree to meet me to discuss this, because it is one thing to say that we are going to have a great technology expansion, and quite another when some of the basic building blocks are being reduced or taken away.
On public health, which is perhaps the most disappointing aspect of the 10-year plan, the Government had an amazing report from the Chief Medical Officer just before Christmas in which she spelt out the problems of health inequalities and had a tough message for the Government. She said, “You’ve got to take this seriously”, and that hard fiscal measures to deal with obesity and some other public health issues are really the only way to make an impression. The 10-year plan ignores this altogether. My interpretation of it is that it is all down to individuals, and only individuals, to improve their own health. It is very disappointing that the Government have chosen to ignore the words of wisdom from their own Chief Medical Officer.
I want to touch on targets. As noble Lords will know, the standards for the NHS are set out in the NHS constitution but they are not being met. The plan is silent on this. The only thing that we know, from an announcement this week, is that the four-hour A&E target will be changed and relaxed. I know that the argument from Simon Stevens is that the target will be prioritised for the most serious illnesses. I understand that and accept the reasons for it. The problem is that for conditions that are felt to be a lesser priority, the four-hour target will no longer apply. I really worry that we will go back to the bad old days of people waiting for hours and hours in our A&E departments.
Whatever the views on targets, I have no doubt that that four-hour target helped to smarten up the NHS. It got rid of a lot of the fears the public had about long waits. The president of the Royal College of Emergency Medicine has warned that scrapping the four-hour target will have a near-catastrophic impact on patient safety in many emergency departments. This decision appears now to have been made but I hope that the Government will ask NHS England to look again at it.
I come to social care, on which the plan has nothing to say of any importance whatever. The plan actually looks as if it was written by NHS managers, and to produce a 10-year plan without having local government as your full partner to it is quite remarkable and very disappointing indeed. We are still waiting for the Green Paper. We have no idea what will happen to long-term funding for social care. How on earth can the plan be delivered unless social care is a full partner to the health service, and unless local government is brought right inside the building to share the decisions on the future? The one thing I would say to the Government is: for goodness’ sake, where in the report is the social care plan that will complement what is clearly the desirable aim of the 10-year plan itself?
I very much welcome this debate and am delighted that so many noble Lords are taking part in it. I think the Government will find that the plan’s aims receive a lot of support from throughout the House and that there is no argument with what the Government seek to do. But without long-term sustainable funding and a workforce plan that links into the requirements of the future, and without the full involvement of local government in social care, they will not be able to pull it off and that would be a great pity.
I turn to the Chief Medical Officer for my final words. In her extraordinary annual report, she spoke of how healthcare is often seen as a cost to the state but she was very wise in refuting that. As she said:
“The NHS and public health services are not a burden on our finances—they help to build our future”,
with,
“the good health of our nation … the bedrock of our happiness and prosperity”.
Amen to that, and I beg to move.
Lord O'Shaughnessy (Con)
My Lords, it is an honour to be given the opportunity to follow the typically penetrating speech of the noble Lord, Lord Hunt. I congratulate him on securing the debate today and thank him for giving this House the opportunity to celebrate the historic investment that the Conservative Government are making in the NHS—I am sure that was his motivation—while giving us the chance to debate how that funding ought to be spent. Constructing a three-minute speech is probably a good discipline for us all, so I will focus my comments today on two issues which are of great significance: integration and innovation.
On integration, the structural centrepiece of the long-term plan is the joining up of healthcare delivery in combined authorities called integrated care systems. This marks a significant departure from 30 years of Conservative and Labour health reform, which had previously focused on creating competition within layers in the healthcare system—primary, secondary and so on. My belief, which I think is reflected in the long-term plan, is that this approach has run its course, not least because it increasingly goes against the grain of the healthcare needs of our people. The median patient is now older, has more complex needs and co-morbidities, and constantly moves between different bits of the NHS to receive their care, so having a vertically integrated healthcare system makes perfect sense.
However, I have two questions for my noble friend that flow from this approach, which as I said is the right one. First, achieving this goal may need primary legislation. Is this something that the Government are prepared to do? If they are, and given the support for integration on the Opposition Benches, the question is whether the Opposition would be prepared to back the Government. Secondly, one concern that has been expressed about these ICSs is that they could create again unaccountable local monopolies. How will the Government counter that risk?
Just as important as making sure that our health service is truly joined up is making sure that patients continue to be able to access life-saving therapies. The NHS has a great history in this area through pioneering surgery, novel drug development, and so on. But as the noble Lord, Lord Hunt, pointed out, the NHS can sometimes look at innovation as something that costs it money rather than making it perform better. I believe that this mindset is changing: look at the sophisticated arrangement between Novartis and NHS England that has led to CAR-T therapies being available here, with the first patient successfully treated; or the sequencing by the NHS of 500,000 genomes in the next five years, bringing truly personalised medicine to people with cancer and rare diseases.
We are making progress, but one critical way in which we can build on that further is to increase the UK’s medical R&D budget. Can my noble friend assure the House that during the upcoming spending review, her department will make a very strong case to the Treasury for a major uplift in the budget of the National Institute for Health Research, which has had a flat-cash settlement over the last eight years? Making the UK the place in the world in which to do clinical research will ensure that NHS patients are among the first in the world to get life-saving and life-changing therapies.
Baroness Walmsley (LD)
My Lords, I too congratulate the noble Lord, Lord Hunt, on his speech. I will focus on obesity and my colleagues will focus on other areas.
Chapter 3 of the plan proposes improvements in cancer, cardiovascular disease, stroke, diabetes, respiratory disease and mental health. But the disease of obesity is often the root cause of these and is one of the top-five risk factors for premature death. Obesity services are mentioned in chapter 2, but the problem is that there is no recognition that obesity is a disease, the prevention and treatment of which is vital to avoiding a wide range of other diseases. Bringing professionals of many disciplines together to work on this in primary care settings is essential to success. This is not all down to the NHS. Local authorities have a big role to play, along with CCGs. However, because of their progressive underfunding, many have had to withdraw services. From 2016 to 2017, the percentage of CCGs reported as commissioning tier 3 services went down from over 68% to 57%.
I was pleased to read that the NHS will provide more access to weight management services in primary care for people with a diagnosis of type 2 diabetes or hypertension with a BMI of 30-plus. But do you have to wait until you get sick to access these services? I was also pleased that the NHS has noticed the remarkable success of the GP Dr Unwin, who got hundreds of his type 2 diabetic patients into remission through low-calorie and low-carbohydrate diets, and is now going to run a pilot scheme of its own. However, professionals working in the field are clear that obesity is not just a lifestyle choice which can easily be reversed by exercising more or eating less—it is much more complex than that. Will the NHS follow the proven cost-effective model of the Fakenham weight management service, which uses a multi-disciplinary team to give personalised tier 3 services to suitable patients? They provide specialist nurses, dieticians, exercise professionals, consultant endocrinologists, psychotherapies and pharmacotherapy, and can refer some for bariatric surgery, which is also very cost-effective.
Recognition of this disease would remove the stigma and mental illness experienced by sufferers, and focus attention on treatment and research. The mechanism of obesity disease is not yet fully understood, but genetics play a part. It appears that the brains of sufferers respond differently to hormones generated in parts of the gut which tell the brain that the person is full and does not want any more to eat. So far, a few drugs have been developed to mimic this normal response, and these have been helpful to many patients. Patients who have undergone bariatric surgery show this phenomenon dramatically. Their diabetes disappears overnight and they lose weight rapidly but do not feel hungry.
Whatever the cause, will the Government make the commissioning of tier 3 weight management services mandatory, because then all CCGs would have to provide them? This could save a lot of misery, and save the NHS millions.
Baroness Donaghy (Lab)
My Lords, I am grateful to my noble friend Lord Hunt of Kings Heath for initiating this debate. Reading the National Health Service long-term plan is like being invited to a party without any food or drink: no money or plan for social care, no budget for training and educating the workforce, no indication of how local authorities will be able to afford their share of responsibility, and no budget announcement for public health. The National Audit Office has said that the crisis in social care, the state of finances in the NHS and the record staff shortages and waiting lists mean that the £20 billion announced by the Government as part of the 10-year plan could be wasted.
I will concentrate on health inequalities. When the Black report on health inequalities was published in 1980, it had a profound effect on me. It was published on the August bank holiday, and the newly elected Conservative Government rejected it. Thanks to Penguin Books, which published it in 1982, it had a wider audience and a huge impact on health inequalities. Yet here we are again. If you are woman living in Kensington and Chelsea or Camden, you are likely to live 7.4 years longer than a woman living in Manchester or Blackpool. A man living in East Dorset is likely to live 9.5 years longer than a man living in Manchester or Blackpool. The Chief Medical Officer’s annual report indicates that,
“a child born in the most deprived areas would have 18 fewer years in good health than one born in the most affluent areas”.
Infant mortality, working poverty and cuts in benefits are on the increase, with the virtual disappearance of local authority support services, including children’s centres and smoking cessation classes. The geographical variation of working-age individuals on incapacity benefit is also stark: a 13% claimant rate in Blackpool; 8% in the south-west of Scotland, south Wales and the north-east of England and Merseyside; and below 4% in most of the south of England. The brutal closure of primary industries in the 1980s made these variations worse.
I would bet that there is an exact correlation between these areas and those who voted to leave the European Union, alienated every bit as much as from Westminster and Whitehall as they are from the EU. Time does not allow me to make comparisons with other countries, but it is not good. To ensure that the long-term plan works, the Government will need to accept the CMO’s recommendations on spending, housing and migration—that, and enormous political will.
Baroness Browning (Con)
My Lords, I too am grateful to the noble Lord, Lord Hunt of Kings Heath, for giving us this opportunity. I pay tribute to the fact that the plan focuses on autism. I declare my interest in the register as a vice-president of the National Autistic Society. The focus on the need to reduce diagnosis waiting times for autistic children and young people is very welcome. Please do not forget the adults in the community who have yet to receive a diagnosis; they are some of the most complex cases for professionals to address accurately.
The need to reduce the number of autistic in-patients in mental health hospitals is something that this House has debated on many occasions, and which I know is a very real problem for many families around the country. The improvement in understanding the needs of people with learning disabilities and autism within the NHS generally has improved, but there is still much to be done. There is also the issue of increasing investment in crisis support: sometimes we deny people small amounts of support and they end up in crisis. That is one of the most expensive ways to address people.
The long-term plan contains a commitment to piloting a new annual health check for autistic people. That is welcome, but I must say to my noble friend on the Front Bench that it is very important that that is done by doctors and professionals who have a good understanding of autism. If parity of esteem is to mean anything, it must be more than just checking blood pressures and weighing people. Checking the mental health of people on the autistic spectrum is probably almost more important than just checking them physically.
In order to do that, it is important that the GP knows who to call. For many years, the National Autistic Society and others, including the Royal College of General Practitioners, have been calling for improved recording of autism in GP registers, so that GPs know more about the needs of their autistic patients. If we do not have a register, and if GPs do not log who their autistic patients are—even if they do not see them very often—will they know who to call for annual check-ups? It is really important that the need to create a database of who is on the autistic spectrum and where they are is included. That requirement is missing from the report. I hope my noble friend will address that; perhaps she will get back to me and put a letter in the Library of the House. The database has been requested for many years.
On dementia, there is much that is very good in this area, but I hope equally that some of the pilot schemes will not be pilot schemes for too long, and that the process will be speeded up—particularly the side-by-side service provided by the Alzheimer’s Society.
Baroness Masham of Ilton (CB)
My Lords, as president of the Spinal Injuries Association, I join others who have spoken about the seriousness of the NHS and social care workforce. The British Medical Association says that the NHS needs a “robust workforce plan”, including additional resources for training, which is missing from the long-term plan. The Royal College of Nursing says that if the Government do not take appropriate action, NHS England will be unable to improve cancer treatment, mental health and care for more patients at home, as outlined in the plan.
Spinal cord injury is a devastating, long-term condition which leads to complete or partial loss of movement and feeling, loss of sexual function and double incontinence. Access to specialised health services is essential to spinal cord-injured people’s rehabilitation, ongoing physical and mental health, and ability to live independently.
Spinal cord injury centres across the country are increasingly experiencing bed closures, as capacity is sought by their host hospital trusts to meet winter pressures affecting other services. As a result of these closures, it is increasingly difficult for spinal cord-injured people to access specialist healthcare and receive essential treatment for their condition. Without these closures, it has been found that the spinal injuries service needs 54 extra beds to make it viable.
I join Age UK in warning that the number of care vacancies will rise unless the Government take action to allow EU staff to continue to work in the UK. It is said that there are around 110,000 job vacancies in care in England and that around 104,000 care jobs are held by EU nationals. Age UK has said:
“The social care workforce is already struggling but if after a UK withdrawal we shut the door on staff from the EU we’ll make a bad situation even worse”.
The Government should recognise this and allow EU nationals to continue to come and work as paid carers. Coming from Yorkshire, I can say that the latest figures show that almost 4,000 EU nationals are working in adult social care in Yorkshire and Humber.
There are few greater risks to long-term global health than the increasing resistance of many infections to antibiotics. I hope that we will work with other countries across the world to develop new antibiotics and overcome the dreaded killer of antimicrobial resistance.
Lord Turnberg (Lab)
My Lords, I congratulate my noble friend Lord Hunt on a brilliant speech. I strongly agree with him that the long-term plan is heavy on admirable aspirations but short on implementation in at least three areas: public health, social care and the workforce—I shall focus on just public health and the workforce.
In public health, everyone agrees that our biggest challenges are smoking, obesity, alcohol and air pollution. It is interesting that three out of these four are due to what we do with our mouths—someone said that the most dangerous organ in the body is the mouth, and that is even without talking. However, the brain is more dangerous because all these challenges are due to behaviour and personal choice, and if we are to make a difference we have to influence behaviour.
We cannot place all that responsibility under the public health banner alone. Valuable publicity campaigns against smoking and obesity have been led by the Cancer Research campaign. If we are to reduce calorie and sugar intake, it will depend on the actions of the whole of government to persuade the food industry, possibly by legislation, to make a difference. If we look at how we might reduce alcohol consumption, we see that the best way is by increasing duty on alcohol. There is a close relationship between the rate of taxation and alcohol-related diseases: the higher the tax, the lower the rate of liver disease. If we want to change behaviour, it is the responsibility of the whole of government and not just public health in isolation.
However, there is one vital area of public health that clearly needs support, and that is its role in the control and prevention of infectious diseases. It is Public Health England that detects and controls outbreaks of communicable diseases, nips them in the bud and prevents them by vaccination programmes. Will the Minister please take that on board? I am afraid that I should reveal my own bias, as many moons ago I was chairman of the Public Health Laboratory Service.
Now what about workforce, where the plan is silent? With 100,000 staff vacancies, mostly nurses, filling that gap is an enormous challenge. The suggestion that we should increase our efforts to recruit nurses from overseas will only go so far, so we must do better at recruiting and retaining UK nurses. We can do things. The first is to fish in the waters of nursing associates and nursing assistants. A large number of them are desperate to be given the opportunity of a career structure that will put them on a ladder leading to a full nurse qualification. We should make nurse associate posts more attractive by offering them the prospect of career progression. We should do much more to attract back into the profession the many nurses who have retired for one reason or another. We do not make nearly enough use of this resource. Will the Government answer that?
In medicine, we have unfilled hospital consultant posts across the board, but much the biggest danger is the shortage of GPs despite all the efforts of government to bring in pharmacists and others to fill the gaps. General practice has now become an unpopular career. Few going into practice are willing to take on a partnership role, with all the administrative burdens that it entails; many want to work part time and many want to retire early. It is not pay that is the issue; it is the increasing patient numbers, the distractions of paperwork and bureaucracy, and the heavy hand of the commissioners that get in the way of what they were trained to do.
There is emphasis in the plan on multidisciplinary teams and primary care networks—hardly novel ideas. I seem to remember writing about them in my review of London’s health services in 1997, and my noble friend Lord Darzi’s excellent review proposed the idea of polyclinics in general practice. That has not lost its attractiveness now that we are jettisoning competition in favour of collaboration. Will the Minister look at these ideas again?
Baroness Tyler of Enfield (LD)
My Lords, I too congratulate the noble Lord, Lord Hunt, on securing this debate. Like him, I think that there is a lot to welcome in the long-term plan, particularly the commitments to increased investments in mental health, primary care and community care, as well as the emphasis on prevention and health inequalities.
However, there is also much to worry about—mainly things about which the plan is silent. The NHS does not operate in isolation, and I am concerned—like many other noble Lords—that many of the laudable aims of the plan are being directly undermined by cuts elsewhere to public health and social care budgets. For example, the plan’s commitment to a more concerted and systematic approach to reducing health inequalities is welcome, but it comes at a time when public health funding has been reduced in real terms by some £700 million in five years, according to the LGA. So my first question to the Minister is simple: do the Government plan to reverse these cuts to public health?
Adult social care is facing a £3.6 billion funding gap by 2025. With such a focus on prevention in the plan, it simply does not make sense to underfund social care. In fact, according to the National Audit Office, one-fifth of emergency admissions to hospitals are for existing conditions that community or good social care could manage. Unless we invest sustainably in social care and public health, the funding in the plan will not be well used. Given the vital role social care will play in the success or failure of the plan, it is a great shame that the Green Paper was not published alongside it. Could the Minister give a firm commitment on when the social care Green Paper will be published?
While proper funding is vital, services cannot operate if we do not have the workforce to run them—a point that has already been clearly made this afternoon. The National Audit Office has warned that the NHS will not be able to use its new funding optimally, precisely because of staff shortages. This is a particularly pressing issue for adult mental health services, where more than 20,000 mental health positions in England are currently vacant. These positions are simply not being filled fast enough. According to the charity Mind, mental health trusts employed more than 179,000 staff in August 2017. A year on, this figure had risen by only 1,500—nothing like the additional 21,000 mental health practitioners the Government themselves said were needed to treat the additional 1 million people by 2021. Could the Minister give a date for when the NHS workforce plan will be published?
Finally, I will draw attention to the continuing issue of out-of-area placements for mental health in-patients, about which the plan says little. At the end of June 2018, NHS Digital reported some 680 active out-of-area placements, of which 95% were deemed “inappropriate”. Could the Minister say what precise plans the Government have to tackle the use of out-of-area placements in mental health services?
Baroness Watkins of Tavistock (CB)
My Lords, I congratulate the noble Lord, Lord Hunt, on securing this debate, and draw attention to my interests as set out in the register. Like other noble Lords, I welcome the plan and the certainty it brings to health service funding, and in particular the aim to achieve parity of esteem between mental health and physical health through investing in the causes and consequences of poor mental health.
However, it is vital to provide truly integrated social and healthcare services in our population to promote healthier lives and provide support and treatment to those with a range of disabilities, including both physical and mental health conditions. Yet we still await the Government’s Green Paper on social care, which is another essential part of the jigsaw. Without clear indications of the funding source available for social care, the implementation of the NHS plan will flounder, with many people remaining in hospital when they are ready for discharge—not only older people with comorbidities but younger people with learning disabilities and autism, a proportion of whom are still in institutional care despite all political parties’ commitment to eradicating this approach.
Public health budgets have been cut since 2015, yet we know, for example, that for every publicly funded pound spent on contraception there is a saving of £9 over 10 years—before considering the wider societal costs and impacts of unplanned pregnancies. The number of health visitors is being reduced in many local authorities—not necessarily because decision-makers want to do so, but because they must make provision for minimal statutory services, so they are faced with selecting the least-worst options to balance budgets. How swiftly will PHE budgets be restored and increased so that both contraception and health visiting services can be adequately provided?
The noble Lord, Lord Turnberg, and the noble Baroness, Lady Tyler, spoke eloquently on workforce issues, but I want to draw attention to the fact that, while we talk about the NHS having a shortage in the region of 40,000 nurses, there are a number of vacancies in the voluntary and independent sectors—particularly in nursing and care homes. At a conservative estimate, there is a shortage of at least 60,000 nurses in England. Yet the NHS plan says that by 2028 it will improve the vacancy rate by 5%. A simple arithmetic equation tells us that this means only 2,000 more nurses. What impact will this really have in assisting the delivery of the new plan?
Finally, there is a section in the plan relating to limiting A&E admissions for alcohol-related problems. This is an excellent aim, but surely the swiftest effective approach would be to introduce a minimum unit price for alcohol, as adopted in Scotland and recommended by medical experts in public health, not only in England but internationally. Could the Minister tell us how the review on minimum unit pricing in England is developing?
The Lord Bishop of Carlisle
My Lords, this NHS long-term plan is very welcome, and from these Benches I commend all those who contributed to it. It is a comprehensive plan—not easy when health is such a wide-ranging topic. It is also realistic about the many challenges we still face. When it comes to issues such as smoking, alcohol dependence and air pollution, I applaud the strong emphasis on public health and prevention, along with the necessary reminder that responsibility for our own health does not belong solely to other people.
This is also an ambitious plan. The noble Lord, Lord Hunt, whom I thank for this debate, referred to it, in true “Yes Minister” style, as “courageous”. In particular—the noble Lord, Lord O’Shaughnessy, reminded us of this—it promises the creation of integrated care systems across England by April 2021 to deliver the triple integration of primary and specialist care, physical and mental health services, and health with social care. This was an important plank in the report of the Lords Select Committee on the future sustainability of the NHS, many of whose recommendations have, I am glad to say, been picked up by this long-term plan. Of course, in practice, as the noble Lord, Lord Hunt, pointed out, this integration will be greatly affected by the details of the forthcoming Green Paper on social care, which has been repeatedly postponed. So we look forward to that and, in due course, as we have also been reminded, to the promised workforce implementation plan.
Others have raised questions about this plan. If I have a criticism, it is that I could find no reference within it to spiritual care, which is offered by chaplains so faithfully, day in, day out, not only in hospitals but now in many GP practices. It can make a big difference to health outcomes and to the general well-being of relatives and friends, as well as patients. This is one of the things that the NHS was set up to provide, so it comes as a rather surprising omission. I am sorry if it is there but I have missed it.
That is also a reminder, should one be required, of the need for effective partnerships between the NHS and organisations in the community and voluntary sector that are closest to vulnerable people or which represent the needs of particular groups that are easily forgotten or left behind. I think in particular of those who work with minority ethnic mental health issues, and countless volunteers who are committed to tackling the increasingly prevalent problems of loneliness and isolation, with all the implications they have for the mental, physical and emotional health of elderly people especially.
The Church of England, together I am sure with other faith bodies, will do everything it can to work with everyone concerned to achieve the plan’s goals, for which we are grateful—although, as others have observed, we are only too well aware of the gap that exists for every institution between aspiration and implementation, and the desperate need for adequate resources in and for the NHS.
Lord Ribeiro (Con)
My Lords, Secretary of State Matt Hancock, on taking up office, identified three priorities for the NHS: workforce, technology and prevention. The ambitions set out in the plan cannot be realised without significant improvements in the health and social care workforce. It is therefore disappointing, as other noble Lords have noted, that neither of these plans was published alongside the NHS Long Term Plan, and we will have to wait until the end of the year. Similarly, funding for medical training is welcome, increasing training places from 6,000 to 7,500, but post Brexit more places may be required. NHS Improvement reported 11,576 whole-time equivalent medical vacancies in quarter 1 of 2017-18—a vacancy rate of 9.3%, up from 6.78% in the previous year. This is equivalent to 108,000 clinical staff, including nurses. Add to this the adverse effect of Brexit, which I mentioned earlier, which is likely to reduce nurse recruitment from Europe, and it becomes imperative for us to retain and grow our own staff.
Your Lordships may recall my own interest in preventing smoking in cars with children present. As a surgeon, I was aware also of the effect of smoking on wound healing and, in particular, surgical site infections after operations, the risk of which doubles if patients smoke on the day of surgery. I therefore welcome the plan’s commitment to offer all patients who smoke and who are admitted to hospitals NHS-funded tobacco treatment services to assist smoking cessation. On Public Health England advice, the option to switch to e-cigarettes will be made available. NHS hospitals are an ideal environment to wean patients off smoking, yet the policy on smoke-free zones varies between hospitals and patients are often not given the help they need to quit. There is an aspiration in the plan to achieve an Ottawa model for smoking cessation. It is used in 120 hospitals in Canada and will, I hope, be used in all NHS hospitals by 2023-24. My question to the Minister is: when will the rollout of the Ottawa model in secondary care begin and what funding for smoking cessation programmes will there be over the lifetime of the plan? Finally, can the five-year plan of the Taskforce for Lung Health be reviewed by the Government to consider the areas not covered within the plan?
Baroness Pitkeathley (Lab)
My Lords, like many in your Lordships’ House, I owe my life to the NHS, so I am always glad of any opportunity to praise it, for which I thank my noble friend, as well as for his wonderful opening speech. I welcome any initiative that helps the NHS to thrive.
I shall confine my remarks to how I believe the plan will affect the 6 million carers who underpin any service provided by national or local agencies and whose contribution, as I never tire of reminding your Lordships’ House, is valued at £132 billion every year: roughly equivalent to all spending on the NHS.
Last year, Carers UK surveyed 7,000 carers and asked what they wanted from the NHS. They were clear that they wanted the long-term plan to turn the NHS into the most carer-friendly health service in the world, and that that would entail better recognition for carers, better identification of carers and more support for carers. I am very pleased that the long-term plan makes the specific commitment to be the most ambitious ever set of NHS commitments to carers.
The plan details how NHS England will improve how it identifies unpaid carers and strengthen support for them to help them address their individual health needs. It also identifies that carers are twice as likely to suffer from poor health themselves compared to the general population. To combat this, the quality marks for carer-friendly GP practices will help carers identify GP services that can accommodate their needs. There is also national adoption of carers’ passports, which will be helpful.
These are welcome initiatives, but the survey last year found that, even among those carers caring for more than 50 hours a week, as many as one in five said that their GP had no idea that they were a carer, and, even when they knew, only one in 10 had been given advice about where to get support. Can the Minister give more detail about how this identification will work in practice and what support will be given to GPs to enable them to give the help that I know they want to give?
The plan also promises better support for carers in emergencies, and support for young carers is also welcome. I want to know more about plans to support the thousands of carers who are in the NHS workforce. So many of them are juggling their work responsibilities with their unpaid caring responsibilities. Support for them in the workforce is vital if enough staff are to be retained to give the plan even a ghost of a chance of being delivered.
Other commitments in the plan also help carers: for example, social prescribing and the joining up and co-ordination of care. As ever, the important part is not the plan but how it will be implemented in local areas. The patchy record of STPs and integrated care systems may give us some anxiety about that. Above all, there is a real sense that this is a missed opportunity. This is a three-legged stool with only two legs. Alongside the NHS plan, we urgently need ambitious proposals for the funding and delivery of adult social care that have the huge contribution made by carers at their heart. The social care Green Paper, when published—I am tempted to say, if published—must set out concrete measures to support carers and give them practical support without putting their own lives on hold. The future of the NHS itself, as well as the system of social care, may depend on it.
Lord Low of Dalston (CB)
My Lords, I congratulate the noble Lord, Lord Hunt, on securing this debate. There can hardly be a more timely and pertinent subject for debate at present than the case for a fully funded, comprehensive and integrated health and social care system in the context of the new NHS Long Term Plan. We have only three minutes, so I shall concentrate on just one thing which I actually know something about: eye health and visual impairment. In doing so, I declare my interest as a vice-president of RNIB and co-chair of the All-Party Parliamentary Group on Eye Health and Visual Impairment.
Sight is the sense that people most fear losing. Ophthalmology has the second-highest number of out-patient appointments of any specialty. Due to demographic factors, the number of people in the UK affected by sight loss is projected to rise by more than 10% by 2020 and more than 40% by 2030. The British Ophthalmological Surveillance Unit—BOSU—found that more than 200 people every year experience severe and permanent sight loss due to delayed and cancelled appointments. Yet, extraordinarily, there is no mention of ophthalmology in the long-term plan.
For these reasons, my all-party parliamentary group undertook an inquiry into capacity problems in NHS eyecare services and the commissioning and planning of such services in England. The inquiry was supported by an independent secretariat hosted by RNIB, and funded by the Bayer pharmaceutical company, which had no role in the scope, development or delivery of the inquiry, however. The inquiry’s report—See the Light: Improving Capacity in NHS Eye Care in England—was published last June and contained 16 recommendations. Obviously I cannot go into all of them in any detail now, but they include measures: to ensure that eye health is accorded higher priority; on how capacity issues are addressed by sustainability and transformation partnership plans; to ensure that the national tariff for ophthalmology does not disadvantage patients at particular risk of avoidable sight loss who require follow-up appointments; and to ensure that patients requiring follow-up appointments are seen within clinically appropriate timescales.
Finally, eye clinic liaison officers—ECLOs—play a vital role in signposting patients to support in the community following the often devastating trauma of a diagnosis of sight loss, but their availability is patchy. RNIB is therefore calling for all ophthalmology departments to offer ECLO support. I would be glad to learn from the Minister the department’s thinking on how ECLO services could be rolled out throughout the eyecare service, and to hear that the department is both taking our all-party group’s recommendations seriously and working for their implementation.
Baroness Cumberlege (Con)
My Lords, my interests are in the Lords register. This debate is opportune because today we heard an announcement from Simon Stevens on the first steps to implementing the plan.
The NHS is frequently likened to a sea-going tanker. I do not agree with that; I think it is more like a flotilla. Numerous boats sail in the same direction but when the storm rages, the flotilla disintegrates, with each ship seeking its own safe harbour. The 2012 Act enabled disintegration, which is why this plan is so crucial. It seeks to cement new systems to integrate health, on a population base, through integrated care systems. Along with other noble Lords, I welcome that.
The wise and wonderful Sir Cyril Chantler published in the Lancet:
“Medicine used to be simple, ineffective and relatively safe. It is now complex, effective and potentially dangerous”.
That emphasis on being potentially dangerous has driven us to consider how we can make medicine safer while recognising its complexity and the need to involve patients, consumers and citizens. The plan assures us that having a baby is now safer than it was 10 years ago, which we welcome. Nevertheless, giving birth in this country is not as safe as in Sweden. Why? Its teamwork is awesome: it learns from mistakes and avoidable harm, then spreads the learning. We do not. The maternity review fashioned a system based on the Swedish system, called “rapid resolution and redress”. We have no confidence that the department will introduce it, so I would welcome some support from the Minister to enable that to happen.
We know that we can improve safety by ensuring that women have continuity of care from the health professional, usually the midwife, to care for her through her pregnancy, the birth and the early days of parenthood. Research shows that with continuity, 19% of women are less likely to have a miscarriage, 24% are less likely to experience a pre-term birth and 16% are less likely to lose their baby overall. Should we be surprised by that? Of course not; it is common sense and it is what women seek. Technology has its place and can aid continuity through the use of iPhones, emails and so on, but when it comes to maternity care, robots are not the answer. Women want the skills, the personal knowledge and the relationship they have with their professional friend. Being handed from one midwife to another does not make for a good experience or aid safety. Continuity does, which is well understood in the long-term plan.
Lord Rogan (UUP)
My Lords, I thank the noble Lord, Lord Hunt of Kings Heath, for providing the House with the opportunity to debate the NHS. The Motion refers to parity of esteem. But, in the continued absence of a devolved Government at Stormont, I would argue very strongly that the people of Northern Ireland are not being given parity of esteem in healthcare. A recent study commissioned by the Northern Ireland Department of Health revealed that healthcare professionals are struggling to keep the local NHS running.
The Medical School Places Review has found that there are currently 110 specialist doctor vacancies in the Province and an additional 580 specialist doctors will be required in Northern Ireland over the next seven years. The report helpfully includes proposals to address the shortage of specialist doctors, including an increase in training posts and the construction of a new medical school in Londonderry. Responding to the report, the Northern Ireland Department of Health has said that implementing the proposals would cost £30 million a year. However, it has admitted that the money would have to be diverted from funding other local authority services. It also stressed that any new medical school would require approval from a Health Minister. But I would remind your Lordships that Northern Ireland does not have a Health Minister. In fact, we have no devolved Ministers at all and there is no prospect of any being appointed for the foreseeable future while Her Majesty’s Government play footsie with the DUP to stay in office. The situation is becoming scandalous.
Waiting lists in Northern Ireland are substantially worse than in the rest of the United Kingdom. Department of Health figures published in September 2018 showed that 94,222 people in Northern Ireland were waiting longer than 52 weeks for their first consultant-led out-patient appointment. Equivalent statistics for the whole of England showed that just 3,464 were waiting for such a prolonged period. The Royal College of Nursing has recently warned that patient safety in Northern Ireland is being compromised by a shortage of more than 1,800 nurses in hospitals alone. We are also struggling for GPs. There are currently more than 3,000 patients per GP in Northern Ireland, which is unsustainable. Yet the people of Northern Ireland, patients and medical professionals alike, are expected to put up with this as the winter turns increasingly bitter.
Doctors, nurses and other NHS workers cannot be expected to deliver for patients at the levels they do without the necessary support. That includes support from properly accountable Ministers serving in a devolved Administration and scrutinised by locally elected political representatives. The NHS belongs to all of us. I invite the Minister to convey my concerns.
Lord Chadlington (Con)
My Lords, I join others in thanking the noble Lord, Lord Hunt of Kings Heath, for initiating this important debate. On page 43 of the long-term plan there is, as far as I know, the first prominent planning reference to the mental health issues associated with gambling. The Government have committed to establishing centres nationally for gambling treatment, saying:
“We will invest in expanding NHS specialist clinics to help more people with serious gambling problems”.
This is welcome news and a hugely important step forward. However, the plan fails to submit gambling to the same forensic analysis adopted for the use of alcohol or tobacco, where careful consideration is given to education, cessation, prevention and treatment. I remind noble Lords once again of the litany of gambling figures based on information currently available. There are over 430,000 adults with a serious gambling problem, but only 2% are in treatment; 2 million are in danger of addiction; 55,000 children aged between 11 and 14 are already addicted; 75,000 children are at risk; and an estimated two gambling-related suicides occur every working day. Could there be a more compelling case for education, cessation, prevention and treatment programmes?
I am extremely encouraged by the recent meetings I have had with senior executives in the gambling industry. Some are voluntarily adopting initiatives such as doubling their industry levy or advertising tools to control excessive gambling. This clearly demonstrates an appetite for change. However, there is still much more to be done. I therefore ask the Minister, first, whether gambling could be considered in the NHS Long Term Plan in precisely the same way as alcohol and tobacco. Secondly, can the Minister confirm that the Government have held, or are planning to hold, conversations at the highest level with the gambling companies and other stakeholders to find common ground for voluntary and constructive reform?
Baroness Gale (Lab)
My Lords, I thank my noble friend Lord Hunt for bringing this important debate before us today. I declare an interest as a co-chair of the APPG on Parkinson’s.
The NHS sees 12.5 million neurology-related cases each year. People with neurological conditions have the lowest health-related quality of life of any long-term condition. Public Health England’s 2018 neurology mortality report showed that the number of deaths in England relating to neurological disorders rose by 39% over 13 years, while deaths in the general population fell by 6% over the same period.
While the NHS Long Term Plan details improvements in stroke services, there is no mention of neurology more broadly. Many serious neurological conditions, such as Parkinson’s, are not mentioned, so while the NHS Long Term Plan contains positive steps for mental health, there are still significant concerns about how these services will work for people with Parkinson’s. The recent findings of the All-Party Parliamentary Group on Parkinson’s report Mental Health Matters Too, which I chaired, exposed the difficulties that people with Parkinson’s face in accessing high-quality mental health care. Mental and physical health services currently operate in isolation, leading to disconnected care. Clinicians are experiencing problems accessing patients’ notes and there is poor communication between services.
People with Parkinson’s rate access to a specialist Parkinson’s nurse as their top priority. Nurses are more accessible than consultants and offer the specialist knowledge and support that many GPs cannot. In the 2017 Parkinson’s UK “Your Life, Your Services” survey, those who had access to a Parkinson’s nurse reported higher levels of care, support, information and control over their health, and fewer hospital visits. There are currently 380 Parkinson’s nurses in the UK, approximately 100 fewer than needed. Measures in the plan to increase nursing levels are welcomed, but I hope this includes Parkinson’s nurses.
I have two questions for the Minister. What steps will the Government take to ensure that the forthcoming workforce plan includes measures to increase Parkinson’s nurses and therapist services to address the rising number of people with the condition, set to be 170,000 by 2025? What action is being taken to ensure physical and mental health services are joined up for people with Parkinson’s?
Lord Scriven (LD)
A plan for personalised and predictive systems of healthcare linking together genomics, big data, artificial intelligence and digitisation—is this real or just fantasy? This is the NHS, which recently said no fax machines by 2020, yet the plan trumpets that by 2024 all secondary healthcare organisations will be digitised. This statement may in time be found to be a different type of artificial intelligence.
The NHS will embrace these new ways of working but the Government need to be realistic on the route map and the investment needed to do this. To make this happen the NHS needs to attract, train and retain a digital-literate workforce and have open-source systems that have operability across the health and social care systems. I see nothing in this plan about digital linkages between health and social care.
Also, the NHS must be trusted on cybersecurity. Last year, every trust tested by the NHS failed on agreed cybersecurity standards, yet the plan says that there will be fully digitised secondary care by 2024. What risk assessment has been done on this target when it comes to data and cybersecurity? What work is ongoing and with whom to ensure operable seamless systems between health and social care?
The plan states that within three years community staff will have access to mobile digital services. A 2018 survey showed that in community nursing this could not happen as in 81% of cases poor connectivity at the patient’s home stopped it. In 33% it was thwarted by uploaded data that could not talk to other systems it needed to. What other non-NHS departments and mobile network companies are part of this plan to make mobile digital working happen and is the three-year timescale realistic?
This service change will need a workforce that is digitally literate, yet the plan has only eight lines on a digital workforce: unfortunately, it gives a top-down approach through the digital academy. Let us be clear: for this to work, the NHS needs at every level a workforce that is digitally literate and equipped to exploit the personalised and predictive care system that the plan articulates. What workforce planning is happening over and above the digital leadership academy to ensure full digital skills for healthcare staff?
To date, £2.8 billion investment is agreed for IT and digital change until 2021. However, the Health Service Journal in 2018 reported that government estimates showed that £13 billion of investment was needed, of which 60% is revenue not capital. What investment over the £2.8 billion has been agreed for the plan’s digital transformation?
The plan is ambitious for a digitised personalised and predictive care system but it needs to be based on realistic plans and firm investment to make it happen. I hope the Minister can answer the questions I pose to show that this is the case and not just aspiration wrapped in hope.
Baroness Neville-Rolfe (Con)
My Lords, I refer to my interests, notably as a director of Health Data Research UK. I congratulate the noble Lord, Lord Hunt, and would like to join him in any meeting on data. I thank the Library for producing an excellent note for this debate.
I am quite new to health as a public policy issue—encouraged by the noble Lord Patel—and have considered the plan de novo. The response has shown that there is overwhelming public support for the NHS and we must take full account of that fact. However, that ought not to prevent us from recognising that the structure of the NHS has drawbacks. I will mention two. It is vast, and therefore bureaucratic, and all experience shows how difficult it is to maintain high levels of efficiency in large bureaucracies. Also the NHS, by its very nature, makes little use of market pricing, making the optimum allocation of resources close to impossible. We must do our best to eliminate inefficiencies, but the NHS is ordained to suffer from some of them.
Given my commercial experience, I regret the overuse of percentages in the plan and the lack of key overall numbers on expenditure and capital formation and on future demography, which is too often ignored in public investment. Value for money is also given very little prominence. Less surprising is the total absence of the notion of enterprise and incentives. This is a pity as GPs are small businesses, and the best are good businesspeople. The fact is that management skills are needed to deliver effective change. The “lean thinking” principles trained into retail could help to cut out waste and blockages. I was reminded of this by the example on page 19 of ambulance paramedics stuck on a hospital ramp with other calls piling up that they could not get to.
I commend the Government on the new focus on digital, personalisation and data. AI is improving the efficiency of drug trials, and there could be vast savings from introducing patient apps for patient records. This would allow easy migration and an end to the familiar cry, “They have lost the notes”. Apps could be introduced immediately for maternity and to replace the red baby book.
I would also like to see support for HDR UK’s digital innovation hubs for the safe sharing of data in R&D and better use of data to improve outcomes—for example, on cancer and antimicrobial resistance. This huge global health issue receives a modest mention on page 39. Are noble Lords aware that, without new antibiotics, routine operations could become too risky and that cancer and paediatric care could become extremely difficult? I welcome the Health Secretary’s initiative at Davos, but we also need worldwide efforts to reduce irresponsible antibiotic use for animals. I was glad to hear the CMO referencing the red tractor label, whose standards have helped to reduce antibiotics on farms by 40% over five years.
I look forward to an annual update on the whole long-term plan and to seeing some quick wins from this enormous investment of money, time and effort.
Baroness Wheeler (Lab)
My Lords, I, too, congratulate my noble friend on securing this debate and on his excellent speech. There is much to commend and welcome in the NHS Long Term Plan. However, the key questions on how it is to be delivered in the light of the realities of the huge injection of cash the NHS needs on top of what has been pledged by the Government, how integrated care is to be achieved without addressing the funding crisis in social care and, without any indication in the plan, how the chronic shortage of staff in key professions is to be addressed all remain to be answered.
My contribution today is on specialised health services. These typically cover small patient populations, collectively treat hundreds of thousands of patients every year and cannot sensibly be planned, procured and provided at a local level. One in 17 people will be affected by a rare or complex condition at some point in their life. I declare an interest as a voluntary vice-chair of the cross-party Specialised Healthcare Alliance, which comprises charities and voluntary organisations, large and small, representing and campaigning for people with rare diseases and complex health conditions, and corporate supporters.
Many specialised services provide for people with rare genetic conditions, while anyone might need to call upon others, such as spinal injuries and serious burns. Under the Health and Social Care Act 2012, NHS England is the sole direct commissioner of all specialised services. It has a current annual budget of £16.6 billion of the NHS total spend. Before the Act, services were planned at either local or regional level, but in effect much of NHS England’s approach almost from the beginning of its existence has been to shift the balance back towards local decision-making. Indeed, the NHS Long Term Plan and last year’s supporting planning guidance represent the latest in a long line of attempts to get the balance right between national and local responsibility for planning specialised services. There are now to be planning boards across areas, with alternative collaborative arrangements in some circumstances.
Guidance so far is vague on structures, processes, procedures and timescales, so I have some key questions for the Minister and I ask her to write to me if she is unable to respond today. First, we are told that 70 services might benefit from local collaboration, with mental health, cancer and learning difficulties prioritised in the first instance. When will further details of the changes and processes for moving to the new structures and of the decisions on which services are to be provided locally be announced? What forms of alternative arrangements will be permitted?
My second question relates to the key issue of consultation with local services, patients, carers and representatives of patient organisations. NHS England seems to have learned from past experience of seeking to drive through changes without sufficient consultation and involvement. Can the Minister reassure the House that the new specialised planning boards will embrace the provisions and spirit of patient involvement in the 2012 Act and include patients and public representatives, who will be meaningfully involved in decisions about the way their care will be delivered?
Finally, there must be clear and transparent accountability and oversight when service planning is delegated to local level. Can the Minister confirm that NHS England will retain overall accountability for all specialised services, and can he also confirm when formal accountability arrangements will be published? NHS England’s vision for specialised services presents important opportunities to improve patients’ experience of care. If it is to be realised, NHS England must take a transparent and collaborative approach to working with the public and patient organisations.
Lord Bird (CB)
My Lords, I am very grateful to the noble Lord, Lord Hunt, for this opportunity to talk about health.
If you really want to cheese off anybody from the health industry, when they start talking about not having enough doctors, nurses and assistants, you might choose to say, “Well, maybe the problem is that you’ve got too many patients”. I have tried that out in many places and have cheesed people off. However, when I tried it out on my GP, he said, “That’s very interesting. If I had 25% fewer people to handle, I could do a much better job than I am doing now”. The question of whether there might be too many patients rather than not enough doctors was raised by Matt Hancock, the Health Secretary, the other day when he said that we spend £97 billion on curing disease and £8 billion on prevention.
I first went to school as a child after the Second World War in 1951. Back then there was social medicine, with an enormous amount of National Health Service involvement in the lives of young working-class boys—even boys from the slums—in an attempt to prevent illness. We were given so much help that I think many of us have remained healthy. That is borne out by my reaching my 73rd birthday yesterday, which is an enormous surprise if you consider all the things that I have done to myself. It has not been the National Health Service that has helped me but I am still here, and I put it down to some of that early stuff back in the slums, when they got us running around, drinking milk and water, looking at our memberships, inspecting our hair and all sorts of wonderful things like that. However, I will not go into too much detail.
I am also interested in whether it is possible to look at the National Health Service as the very epicentre of our society, reinventing the concept of health over the next 20 years. I do not think that we should leave health to doctors or nurses; you should go to them only when something goes wrong. A very nice report by the Big Issue and CILIP on libraries and the reasons for supporting them proves that £27 million was saved for the National Health Service by running libraries and attacking the problems of loneliness.
I was on the train today and met a woman who was going to Addenbrooke’s Hospital for the last session of chemotherapy on her breasts. She went with a fierceness, and I thought to myself, “God bless her”. It will increase her chance of surviving if her mental well-being is improved by a sense of happiness, hope and optimism, and that is what is created by areas outside the National Health Service. We have to reinvent the NHS so that it is the very epicentre of everything, with libraries, schools, universities and prisons all linked together.
Lord Holmes of Richmond (Con)
My Lords, I congratulate the noble Lord, Lord Hunt, on securing this debate. I also declare my interests as listed in the register.
In the time available, I will limit my comments to the potential of elements of the fourth industrial revolution which could be deployed to assist the National Health Service and all healthcare. In fact, I will limit myself to two elements: artificial intelligence and distributed ledgers. Artificial intelligence has incredible potential to augment, not replace, our clinicians and so transform diagnosis and care. Let us consider the work that has been done at Moorfields, where artificial intelligence is being deployed to analyse hundreds of thousands of retina scans—something that it would be impossible for one person to do in a lifetime, never mind a career. Here artificial intelligence is not replacing but augmenting the consultants who are working in that area.
This goes beyond the business of healthcare into the business of the NHS itself. Let us consider the number of missed appointments, costing over £1 billion to the National Health Service. Artificial intelligence certainly has a role to play there. As we set out in the report of the Select Committee on Artificial Intelligence, published last April, were the United Kingdom to deploy ethical artificial intelligence effectively, we could be not just a world leader but a world beater. There can be no better place to do this, and no better illustration of it if we get it right in the NHS—and indeed across all healthcare.
I turn to distributed ledgers, which are often called blockchain but, in relation to how they are deployed, it is better to describe them as distributed ledgers. These are effectively immutable, anonymised, decentralised records with huge potential in healthcare for drug safety and security, care assurance and many other examples. But again, let us go beyond elements that impact directly on care. Currently, the NHS spends 25,000 doctor days on assuring the identity of people coming into the service. Assured ID is of course incredibly important, but there are many different ways of doing it. Imagine those 25,000 doctor days being deployed on patient care.
There is much disagreement around the potential of 4IR in health and many other areas but there is broad agreement on the critical and central importance of data. Data underpins all this; with NHS data comprising some 65 million patient records, it has extraordinary potential, although massive risks and issues remain to be understood, not least the almost singular lack of interoperability within the service. Practical problems also have to be considered against legal, cultural and ethical considerations.
Can my noble friend the Minister outline the Government’s plan to address probably the greatest epidemic in the NHS—that of data fragmentation? Data has always underpinned health innovation. Dr John Snow used it to isolate the cause of cholera and Florence Nightingale to revolutionise hospital hygiene. The NHS currently produces a proliferation of data but is all too often stymied in its ability to use and deploy it because of the aforementioned fragmentation.
I am in no sense naive about the issues, risks and challenges of deploying these new technologies. To put it simply, we need to ensure that trust is fully and firmly at the centre of all our trusts.
Consider the immutability of all patient records—being able to have a single source of truth, your patient record, in your hand, alongside the trusted, immutable tracking of your timestamped record, including everyone who has accessed it and why. None of this is straight- forward. There is so much that the organisation must do to get to a position even to consider many of these technological possibilities, but they are possibilities. If the NHS is an oil tanker, it is an oil tanker that has to climb a mountain. That is not easy.
If we get this right, even partially, we will not just have a National Health Service that is a world leader in patient care. We will have a National Health Service that is a leader in the adoption and deployment of artificial intelligence and distributed ledgers for public good: a service fit for the future enabled by the 4IR. That is a possibility, not an inevitability.
Viscount Hanworth (Lab)
My Lords, this debate has been rich in its detailed treatment of particular issues but I shall talk only in general terms. At its inception in 1948, the NHS was an expression of the egalitarian philosophy of the Labour Party. At that time, it had the support of many Conservative politicians, but gradually they changed their opinions. They began to favour a health service in which consumers could exercise their preferences in favour of a more personalised provision, if that is what they wished for and if they were able to afford it.
In 2009 several leading Conservatives who were to become members of David Cameron’s Cabinet put their names to a manifesto criticising the NHS. They were calling in effect for the NHS to be dismantled and replaced by a system based on health insurance in which private providers would play a major part. This worried their leader, who was conscious of the popularity of the NHS and of the damage to the Conservatives’ electoral prospects that might ensue if their adverse attitudes towards it were widely perceived. For that reason, he felt compelled to assert that the NHS would be safe in the hands of the Conservatives. Nevertheless, the covert plans to privatise parts of the NHS proceeded unabated. The Health and Social Care Act 2012 was the precursor to its intended privatisation.
Baroness Browning
I advise the noble Viscount from personal experience that David Cameron’s motivation was not political expediency. As I know only too well, he had every reason to be grateful to the NHS because of his son.
Viscount Hanworth
I thank the noble Baroness for that interjection. I do not think the two issues are mutually exclusive; I think there was a very strong consciousness on his part, which may be commendable, that the NHS was very popular in public opinion. Be that as it may, the covert plans nevertheless proceeded, and the Health and Social Care Act 2012 was indeed intended as a precursor to privatisation. The Act aimed to induce competition among the agencies of the NHS and appointed clinical commissioning groups to govern the provision of medical services. These were to be run partly by the general practitioners but they were also to be the point of access for private service providers. The intentions of the 2012 Act have not been fulfilled. This has been due in part to the reluctance of the private sector to pursue the opportunities that have been offered. However, years of neglect and inadequate financial provision have ensued, which have brought the NHS to its present state of crisis.
It is against that backdrop that the Government have commissioned the NHS Long Term Plan that we are discussing today. The report has been authored by health service professionals. It envisages some felicitous prospects and is written in an optimistic spirit. Surely the Government have calculated that such a report cannot fail to do them credit. It is bound to divert attention away from the current problems.
The report recognises some of the major issues facing the NHS. These include the present inadequate funding, the shortfall in staffing, the inequalities of its provision across the regions, the pressure from an ageing population and the demand for innovative and expensive treatments that cannot be afforded easily. The report is remarkably sanguine in what it proposes can be done with a minimal increase in funding. It argues that the prevention of health problems can forestall the need for medical cure. It proposes that the demand on hospitals’ resources can be limited by reducing the number of patients and the length of their residence.
Viscount Hanworth
I am sorry, I am going to take a little more time because some of this was pre-empted.
Lord Rennard (LD)
My Lords, I refer to my interests in the register. As an officer of the APPG on Smoking and Health, I am delighted to see that support for smokers accessing NHS services to quit is a key feature of the long-term plan’s commitments on preventive healthcare. Smoking remains the leading cause of preventable, premature death in England, killing nearly 80,000 people a year and costing the NHS an estimated £2 billion.
I welcome the plan’s commitments to fund new support for smokers to quit when in hospital, for long-term users of specialist mental health and learning disability services, and for pregnant women and their partners. The noble Lord, Lord Ribeiro, has already referred to how measures have been seen to work effectively using the Ottawa model for smoking cessation. Where this model is applied in Canada, smoking status is recorded on admission to hospital, with staff delivering brief advice and providing medication to all smokers. Smokers are then followed up both in hospital and post discharge to provide them with specialist behavioural support. Rates of quitting with this model have improved dramatically, and those in the programme were also 50% less likely to be readmitted to hospital. The plan states that this support will be in place across all hospitals by 2023-24. Like the noble Lord, Lord Ribeiro, I hope that the Minister may today give us an indication of when that rollout will begin and what funding will be made available for this programme over the life of the plan.
The plan’s commitments to support smokers who are long-term users of specialist mental health services, both in hospital and in the community, is also very welcome, but this will rely on upskilling a workforce that is already under great pressure. A survey by Action on Smoking and Health and the Mental Health and Smoking Partnership recently highlighted the very variable training and infrastructure in place to support smoke-free policies in different trusts. We need best practice in all of them.
I also welcome the explicit commitment in the plan for the option to switch to e-cigarettes, in line with guidance from Public Health England and the recommendations from the Science and Technology Select Committee last year. This option will be included in the support available to smokers in in-patient mental health services.
The plan also addresses the issue of smoking and pregnancy. Women who live with a smoker are six times more likely to smoke throughout their pregnancy. I hope the Minister may be able to tell us how additional support for partners, alongside that for pregnant women themselves, will be delivered and whether this will continue during postnatal appointments to maximise the chance for all children to grow up in a smoke-free home.
Successful implementation of the plan’s commitments to smoking cessation is clearly threatened as local authority public health budgets continue to be squeezed, reducing the funding for and availability of community stop-smoking services. I concur with the words of many others by saying simply that, without properly addressing the issues of social care and integration with local authorities, this plan will fail.
Lord Colwyn (Con)
My Lords, there are only eight speakers to go.
I must congratulate the noble Lord, Lord Hunt of Kings Heath, on his comments and explanation of the case for a fully funded, comprehensive and integrated health and care system. The noble Lord is a busy man: today he is talking about the long-term plan, tomorrow he is dealing with organ donations. I am interested as a retired dental surgeon and a fellow of the British Dental Association.
I would briefly like to turn the attention of the House to the issue of dentistry, which is notable by its total absence from the long-term plan. NHS dentistry plays a key role in preventing oral health conditions and it is also a very good early indicator of a range of general health problems. But despite the Government’s insistence that prevention is at the core of their agenda, funding for NHS dentistry per head of population has fallen by 14% in nominal terms in the past five years.
Not a week goes by that we do not hear in the media a report about patients having to travel unreasonable distances to access an NHS dentist, or that they have had to perform some minor operation on the kitchen table. People unable to find a dentist show up at their GP surgery or A&E, neither of which can help them, further wasting precious NHS resources. The ambitions set out in the plan cannot work without significant improvements to the care of the health and social care workforce. Further, it is estimated that 1.8 million older people could have an urgent dental condition.
In the light of all this, I hope that my noble friend can offer some explanation why dentistry is barely mentioned in any long-term plan and what further plans the Government have to improve access to NHS dentistry.
Lord Brooke of Alverthorpe (Lab)
My Lords, I express my gratitude to my noble friend Lord Hunt of Kings Heath for securing the debate. I thank the Government too for producing the long-term plan. I join others in applauding Professor Dame Sally Davies’s annual report for 2018 and the recommendations she has produced on how we might achieve better health in the UK by 2040. It is a particularly impressive document. She is one of the bravest of our public health servants.
I will not say anything on alcohol because that has been more than adequately covered by my friend, the noble Baroness, Lady Watkins of Tavistock, but I will focus mainly on obesity, which is identified in the plan as one of the major problems we face. I share my noble friend Lord Hunt’s disappointment that there is a paucity of public health initiatives in the plan. I support the views expressed by the noble Baroness, Lady Walmsley, and my noble friend Lord Turnberg on the importance of public health co-ordination and campaigning on obesity, which was also indirectly, in general terms, supported by the noble Lord, Lord Bird, who talked about how we need to raise our sights on where we are trying to go.
I have asked this question previously to the noble Lord, Lord O’Shaughnessy: where is the overarching co-ordinated national campaign against obesity? If it is truly the crisis that everyone keeps saying it is, why do we not have one? This morning, Public Health England reminded me of a whole variety of different initiatives it is running, but when I go to my GP and look at the noticeboard announcements, I see notices about smoking, drugs and alcohol, and services for babies, mothers and older patients. Obesity gets barely a mention, yet it is seen as one of the crises facing us. We must return to the topic of the amount of attention given to it centrally.
Last week, we had a very good debate on the inadequacy of local authority funding led by the noble Lord, Lord Scriven. Its focus was again primarily on social care, but there was little mention of the very important responsibilities that now fall to local authorities regarding public health and public health campaigning. That again has been cut because of shortages of money at local authority level. I wrote to the Secretary of State when he took office pleading that he should give this a higher priority. I have had no reply, but maybe the Minister might follow this up to see whether his deliberations continue, and whether he will now respond positively and say that he is prepared to embrace this.
We really have to get a co-ordinated national campaign running, particularly for children. The plan focuses on people with diabetes and people with a BMI of 30-plus, but that excludes thousands of people who are obese and most of the children—there is nothing in it about children.
I tap my watch and see that I have come to the end of my remarks. Plenty of work can be done that does not necessarily cost money. We need to look at how we can engage children with programmes and games that will captivate them and turn their attention to their health. We can also look at cheap activities such as yoga that will help people find a way to look at their health and improve their positive outlook on life. There is much to be done. Is the Minister prepared to embrace some of these suggestions? We could then look forward to seeing a chapter 3 for the child obesity programme. When will it come?
Lord Stirrup (CB)
My Lords, I refer the House to my interests in the register and to the fact that I have family connections with the NHS. In the three minutes allotted to us in this important debate I can really make only one point: that the NHS Long Term Plan contains many worthy initiatives and objectives, but delivering the improvements that it seeks will be an extraordinarily difficult task, especially as we have no overarching strategy for health within the UK. I say this because a strategy must bring together ends, ways and means in a balanced and coherent way. No one issue can be addressed without the others.
When we talk about a fully funded health service, for example, we come face to face with the fundamental problem confronting the NHS and all other health services around the world. How does one constrain cost in a system of open-ended demand and ever-increasing technological opportunity? Without such constraint, healthcare is in effect an unbounded system; we could end up spending 100% of our GDP on it and still not satisfy every demand. The only rational answer is to balance resources and tasks by controlling both, rather than just one of them. This of course means limiting the care that is provided. That already happens, but in an often random and unplanned way. So the question we should be asking ourselves is: what is the most equitable system of rationing?
Whatever system is chosen, it will sometimes lead to unfortunate and perhaps tragic cases which frequently become political causes célèbres, so if we are to decide on the fairest and most efficient system of healthcare rationing, it must be done on a cross-party basis. As long as healthcare is treated as a political football, effective solutions to this conundrum will continue to elude us.
Let me caution against the pursuit of apparently attractive but, in the long term, chimerical solutions. One of the most common is the cry for greater efficiency. The idea that this can be used to wish away the underlying financial dilemma is ill-considered at best and mendacious at worst.
Nor should we think that restructuring healthcare will make the problem any easier. Preventive measures to improve long-term health are important, but they are unlikely to moderate demand for NHS services. We will all, alas, continue to suffer physical, and perhaps mental, deterioration over time. The clinical causes of the deterioration may change, but they will still need to be treated or ameliorated. It therefore follows that improved public health programmes, while essential, will over time likely result in greater expenditure rather than less.
The NHS Long Term Plan covers many important areas and sets out some laudable ambitions. But unless we find a sustainable way of balancing ends, ways and means, we will still not have an effective healthcare strategy.
Baroness Massey of Darwen (Lab)
My Lords, I thank my noble friend Lord Hunt for securing this important debate and for his well-known commitment to health services.
I was particularly struck by one sentence among many in the Oral Statement earlier this month. It said:
“At the heart of the Plan is the principle that prevention is better than cure”.—[Official Report, 7/1/19; col. 2069.]
I agree, but I was disappointed to see that there was not so much emphasis on public health, community involvement, youth health or better cost analysis. Organisations which we know sent briefings and were generally supportive of the plan’s aims. One said that,
“some significant pieces of the jigsaw are … missing”.
Another said that the long-term plan is,
“defined as much by what it omitted as what it contained”.
I will identify some things as I see them. The British Association for Sexual Health and HIV expressed concerns about public health funding—which, of course, supports prevention. These services have been cut in recent years; around £700 million will be cut between 2014 and 2020.
I am also surprised to see no cost-effectiveness figures in the plan. Are they available elsewhere? It is surely important to weigh the potential cost savings from prevention versus treatment costs. The plan states that in April 2019 NHS England will introduce more accurate assessments of the need for community health and mental health services. Will this be done in real consultation with local groups to identify local, specific needs?
Moving on to young people, I thank the Association for Young People’s Health for its analysis. It is important to recognise that early intervention is not just about young children. Adolescence provides a second window, given the massive brain development and growing maturity in sexuality, relationships and reasoning among adolescents. Adolescent services are crucial to any health plan and are not sufficiently addressed in this one, yet they are key to general health.
Last week I was involved in a seminar with young people. One young woman said that we are experts by experience—how true. So are communities experts by experience, and they need to be listened to in order to formulate responses. Will the Government take note of the concerns expressed in this dynamic and wise debate—and, more importantly, will they keep the debate going so that we can all have a say in what is happening to this plan?
Baroness Redfern (Con)
My Lords, I thank the noble Lord, Lord Hunt, for bringing this important debate to the House, and welcome the plan. All the evidence tells us that the UK population is set to grow and age significantly over the next 10 years, with people over 65 increasing by 33% and over-85s almost doubling, against an increase of only 2% in working adults. On the basis of delivering this health prevention agenda against a growing population, in developing this plan and framework the Government and the NHS have worked closely with local authorities, patient organisations, NHS staff and the public so that everyone has the opportunity to contribute.
The shortage of trained staff needs to be resolved if the ambitions in this long-term plan are to be achieved. I am pleased to hear today of the announcement of the biggest reform to GP practices in 15 years, to improve access and create 20,000 more staff for those practices. Supporting staff and boosting morale with rewards for career progression should help to retain our experienced, dedicated staff and help to grow our own.
Reducing and tackling waste with smarter working to improve productivity and efficiency is important. Prevention is the key to transformation—expanding screening and age range—as survival rates can be improved dramatically by earlier diagnosis and early multi-access to treatment. It is about empowering patients to become more effective in managing their own health and to take responsibility as part of their personal decision-making. This long-term plan is ambitious, aiming to transform services using up-to- date technology to provide many more online interventions for patients and so reduce up to a third of out-patient appointments.
With excellent sharing of data—precision diagnosis, the earliest interventions backed up by detailed costs of investment, covering genetic data around performance and outcomes—more capital investment will be required. For example, we need more MRI and CT scanners to improve survival rates. Data collection, handling, storage and sharing to achieve and facilitate IT skills technology saves time and money, so I am pleased to see the Government wanting to invest £440 million in new technology and £75 million in electronic systems to unlock the full potential of biopharmaceutical, personalised medicines, genomics and the identification of applications for stem cells and the development of new drugs—but we need to be much quicker in decision-making on those appraisals.
I welcome the proposed increased investments in primary and community care, focusing on full integration of health and social care, moving out of hospital settings and into the community to deliver more care in the home, as new technologies unleash the ability to deliver a high-quality service so that only patients triaged with more acute or specialised care are in hospital.
Finally, having seen the changes over the past 70 years, I look forward with optimism to the ambitious long-term plan that sets out to modernise the NHS for the next 20 years.
Baroness Jolly (LD)
My Lords, I draw attention to my interests as declared in the register. It is worth mentioning that the noble Baroness, Lady Browning, is the only Peer to have mentioned people with learning disability and autism. In 2015, following the Winterbourne View scandal, there came the Transforming Care programme. Can the Minister outline in a letter or, if there is time, at the end of the debate what progress has been made and whether local authorities received the budgets required to match the services they are delivering?
I thank the noble Lord, Lord Hunt, for calling this debate. The long-term plan is detailed and forward thinking, but without supported staff, sufficient resources and consideration of social care, it is difficult to see how the Government can achieve the comprehensive and integrated health system to which they aspire. The long-term plan is a positive step forward, but it is defined as much by what it omits as what it contains. Without a workforce strategy, the social care Green Paper and involvement of local authorities and not-for-profits, the plan is incomplete.
We have 100,000 vacancies in our health system. The 3.4% uplift in long-term funding for the NHS does not cover key areas of health spending, and uptake of innovation is patchy. By 2030, we could have a quarter of a million vacancies in our NHS, including in key areas such as nursing. We are already suffering from the loss of 5,000 mental health nurses since 2010 and a 50% drop in the number of district nurses in the same period. The number of health visitors is down by 4,000, which does not bode well for children’s services and a healthy early start. My key concern is that, while the long-term plan recognises the workforce crisis, there is no magic bullet. Without solving staffing problems, many of the goals in the plan will go unfulfilled.
The crisis is exacerbated partly because workforce planning in England has become increasingly fragmented and incomplete. Six years on from the introduction of the Health and Social Care Act, it remains unclear who is accountable for workforce strategy and investment. Can the Government confirm where the buck stops for workforce planning for nurses, doctors and care staff? What timeline can we expect for the release of the workforce plan, which will provide more detail on strategy? Is the March date given to the noble Baroness, Lady Harding, realistic? A “quick and dirty” piece of work will give us a picture of what is happening, but it is the resulting timelines for all the strands of this work that will shape the workforce of the future.
I hope that we will see health and social care considered together in the workforce plan, as many other noble Lords have said. Integrating health and social care would, for instance, strengthen our ability to support individuals with multi-morbidities, an area that was relatively neglected in the plan.
The rollout of the “enhanced health in care homes” model, which strives for co-ordination and co-operation between care homes and the NHS, is an encouraging commitment in the plan which recognises barriers to good health and attempts to overcome silos. Overcoming silos can also mean broadening skill sets.
One headline in the plan is the greater focus on training “generalist” doctors. This is a good idea; we should not neglect encouraging broad skill sets at all levels of health and social care. Can the Minister expand on this proposal for generalist doctors? It would require reinvestment in training. In 2006-07, the training and education budget was 5% of the NHS’s total budget, but that has now fallen to 3%. It would cost £2 billion to put the budget back to 5%, but the returns may be far greater, so for the Chancellor it could be a good deal.
Retention of staff is a problem. It is such a waste if trained staff leave for a better-managed, better-paid role elsewhere. A start might be to look at rostering. Complaints about inflexible rosters from nurses, but also of late from junior doctors, make for a culture of stress, leading to staff opting for agency or bank work, where choice or control is possible for the individual but not, of course, for the hospital. Some hospitals do this successfully; others need to copy what is done.
To retain experienced staff, could the Government also encourage employers to pay a living wage to social care workers? This could form part of the social care Green Paper when it arrives. Currently, many in our community are being served by staff who are overstretched and underpaid. Social care staff in hospitals, care homes and the community are the glue that keeps the system together, that prevents admissions from the community and that speeds patients home.
In the past, key medical innovations tended to be within the realms of big pharma. Now innovation appears in the form of med-tech, robotic surgery and other surgical improvements such as delivering TAVI heart valves through the groin. Under a local anaesthetic, this achieves today what before required open heart surgery, with all the risks that entailed. This is not only a surgical improvement; patient stays are hugely reduced and outcomes often immediate.
In the long-term plan, there is a laudable focus on digital health to bolster access to services, which, if carefully implemented, may increase patient satisfaction and help to minimise wasted resources. Some surgeries do this better than others. I had to cancel a doctor’s appointment to take part in a debate tomorrow—I sent a text; they confirmed with a reminder text; all I needed to do was type “absent”, and they cancelled the appointment. Innovation in staff rostering can improve staff and ward morale and allow a better work/life balance.
I have a couple of questions for the Minister, which I am happy to wait for. What support are the Government giving to innovators and early adopters of technology designed for use in operations and other clinical interventions? What changes need to be made to commissioning to accommodate and support innovation?
Looking at the speakers’ list, it is no surprise that this has been an interesting and well-informed debate—it is always going to be the way. There is much and varied experience in your Lordships’ House, and I thank the noble Lord, Lord Hunt of Kings Heath, for tabling the debate.
Baroness Thornton (Lab)
My Lords, I start by congratulating my noble friend Lord Hunt on initiating this important debate. I also congratulate noble Lords on the discipline they have mostly shown in this debate, and on the spread and depth of the views that they have expressed.
I will not summarise the contents of the 10-year plan, because my noble friend did that extremely well in his opening remarks. Noble Lords have covered a great deal of ground in the last two hours, and presented the Minister with a veritable cornucopia of questions to answer—some of which I suspect she may pass over to the new Minister when she arrives here on Monday.
I intend to focus on implementation and finance—chapters 6 and 7—and also make some remarks on digital transformation. There is no doubt that this is an ambitious plan, and it needs to be ambitious. The key question is: how will it be delivered? As noble Lords have said, there are dozens of aspirations in the plan; so far it seems to have avoided the previous pitfalls of promising unrealistic productivity gains and savings from reducing demand.
I was struck by the pertinence of the remarks made by the noble Lord, Lord Kakkar, when we discussed the launch of this on 7 January. He said:
“How are Her Majesty’s Government going to go about developing the metrics to determine how success should be measured? How will they go about providing a baseline picture of the current situation in different parts of the National Health Service so that the purpose and ambition of this plan can be properly measured? Which part of the NHS is going to be responsible for measurement and implementation: NHS England, NHS Improvement or, indeed, the Department of Health and Social Care?”.—[Official Report, 7/1/19; col. 2076.]
Those remarks were echoed by my noble friends Lady Donaghy and Lady Massey. I could not have put it better myself, so I did not try. I hope the noble Lord might forgive me for repeating his questions, because I do not think they were adequately answered on 7 January. They will run through the course of the discussions we will have over the coming period.
These questions are important because the plan fails to set out what success looks like for the patients, carers and staff. It does not set out how worthy aims are to be achieved, and there is no coherent approach to the management of the necessary changes. My noble friend Lord Brooke’s description of obesity perfectly illustrates that.
On implementation, my question here also concerns the somewhat Delphic reference to legislation in the plan. Is this the rollback of the hideously complex and expensive competitive frameworks, with the accompanying bureaucracy, that exist at the moment, referred to by my noble friend Lord Hanworth? Is the Minister able to enlighten the House further as to when and to what purpose this legislation will be scheduled? Indeed, do the ICSs need primary legislation, and what will be the role of local government in them?
On finances, my noble friend Lord Hunt described the finances as “courageous”; I might add that they are rather heroic. As noble Lords will be aware, last summer the Prime Minister announced £20.5 billion extra funding for the NHS by 2023-24. While this is generous compared with other public services, all informed opinion suggests that it is barely enough to keep pace with growing demand for care. As Dr Anita Charlesworth from the Health Foundation says in her excellent analysis, which I recommend to Members of the House:
“This means trade-offs are inevitable, and these must be spelled out clearly so the public know what they can expect from the NHS”.
In a way, that was at the heart of what my noble friends Lady Wheeler and Lady Gale said about specific conditions.
Can the Minister explain how this settlement will do more than keep the show on the road? How much will be available for investment in the aspirations contained in the 10-year plan? Today we learn that a new five-year contract will provide billions in funding for GPs and primary care networks; this is excellent news and a good proposal, but is this money coming from existing budgets, from the £20 billion, or is it new money?
There is no sign of an end to the sustained cuts to public health, capital spending and workforce training budgets. We know that NHS hospitals are in deficit and that the waiting times targets for accident and emergency and planned operations have not been met for three years. There is a crisis in social care that we have to find the funding for, as well as investment for mental health, so there is an enormous amount to do. As my noble friend Lady Pitkeathley asked, how will we fund recognition of the work of carers, for example? The Minister needs to tell us how all these things will be funded.
The chapters concerning science, digital and data are important aspirations: the adoption of personalised medicine, the adoption of genomics to drive diagnosis and the selection of care, the development of a workforce that is able to apply innovation and genomic medicine to the routine care of patients, and the adoption of a digital strategy for patients and healthcare professionals to improve clinical outcomes. I welcome these; they are forward-looking, and in many ways they are the only way forward for a modern health service. The noble Lord, Lord O’Shaughnessy, has been driving this agenda in government, and the work of people such as my noble friends Lord Darzi and Lord Winston and the noble Lord, Lord Kakkar, is very exciting; building international partnerships will take this agenda forward, although I hope that Brexit does not cast a shadow and a cloud over this. I ask the Minister: what is the timetable for the digital rollout? As everyone is aware, the NHS has form on being challenged in delivering these ambitious digital programmes. How will NHS England ensure that it has the capacity to deliver this change, which will be so important?
I would like to raise one issue which we have discussed in your Lordships’ House in the past: the use of NHS data and how to harness the value of healthcare data from government. While the Government say they are committed to maximising the value of healthcare data, there is a growing consensus that a national approach is needed if the UK is not to reach a tipping point beyond which the value of NHS data assets depreciates relative to those invested in and made available on mutually beneficial terms elsewhere in the world—specifically, the complexities of data holdings across would-be integrated care systems. In addition, private sector providers are liable to render it near- impossible for local organisations not to undermine, inhibit or impact the ability of the NHS to maximise the value and use of NHS data. The noble Lord, Lord Freyberg, is right to pursue the idea of the creation of a framework, which he called a sovereign health fund, to ensure that the NHS benefits from this.
This is important because the amounts of money involved are absolutely enormous. For example, the noble Lord, Lord Drayson, says that, for publicly listed fund companies, knowledge assets account for 50% to 80% of the total value. The value held by the UK Government for NHS data could be as high as £1 trillion. That could be invested in our NHS, if we can get the infrastructure right. What is the Minister’s opinion of that? Such figures would make all the difference to our NHS, and I imagine they are very attractive to companies such as Google. It is important that the Government deal with that.
I close by thanking my noble friend Lord Hunt, other noble Lords and the many organisations which sent briefing materials—too many to mention. They tell me that we are at the beginning of a great discussion, and I suggest that noble Lords file debates about the different parts of the 10-year plan that so that we can have longer than three minutes on all the important issues that they raise. That will be a good way to welcome our new Minister to the House.
Baroness Manzoor (Con)
My Lords, I too thank the noble Lord, Lord Hunt, for raising this important debate and presenting the issues in his usual authoritative and well-informed way. I also thank all noble Lords for their valuable contributions; it has been a very well-informed debate and I am certainly learning fast.
I say humbly what a credit it has been to the House to hear about the NHS in a positive light. I understand that there are challenges and noble Lords have put many questions to me. Nevertheless, the support around the House for the NHS plan is very welcome.
It is fair to say that 2018 has been a remarkable year for the health service. As many noble Lords will appreciate, celebrating a 70th birthday is a time to reflect on what has been achieved and to look ahead with hope and optimism. As my noble friends Lord O’Shaughnessy and Lady Cumberlege said, the NHS has begun 2019 by publishing an unprecedented long-term plan for the next decade. The plan sets out a compelling vision of how the health service will provide a safer, more personalised service and more integrated care using technology and new ways of working to deliver more services in one’s own home or community.
To reassure my noble friend Lady Neville-Rolfe, the noble Lord, Lord Scriven, the noble Baronesses, Lady Donaghy and Lady Watkins of Tavistock, and the noble and gallant Lord, Lord Stirrup, I can say that the long-term plan is fully costed and has been developed within the spending settlement agreed with the NHS: an extra £33 billion in cash to reach a total of £148.5 billion in 2023-24. This is the equivalent of £20.5 billion extra in real terms. This increased spending, together with stretching but achievable ambition on efficiency, should ensure that the NHS will continue to deliver the world-class service we all want.
First, I recognise the importance of improving patient experience, safety and flow through hospitals. I agree with the right reverend Prelate the Bishop of Carlisle that spiritual care plays an important part in health outcomes. As the noble Lord, Lord Hunt, will be aware, NHS England is undertaking a clinical review of standards, considering the appropriateness of operational standards for physical and mental health relating to planned, unplanned, urgent or emergency care.
In 2018-19, the Government provided the NHS with an additional £1.6 billion to support and improve A&E and elective care performance. The NHS will use this investment to treat 250,000 more patients in A&E in 2018-19 and improve performance, with the four-hour standard to be achieved within 2019.
Many noble Lords, including the noble Baronesses, Lady Gale, Lady Wheeler and Lady Tyler of Enfield, and the noble Lord, Lord Hunt, inquired about the adult social care Green Paper. The Department of Health and Social Care is in the final stages of preparing it, and it will be published at the earliest opportunity. As noble Lords are aware, building a sustainable care and support system will require big decisions, and the upcoming Green Paper will place on record the extraordinarily difficult choices that we as a legislature and, more broadly, we as a country, must confront.
I understand the concerns raised by my noble friend Lord Hunt—he is a friend—regarding integration. As he indicated, the Green Paper will build on the proposals on integration in the long-term plan, which are the deepest and most sophisticated ever proposed by the NHS. We will invest in models of care that strengthen links between primary care networks and local care homes, as my noble friend Lord O’Shaughnessy laid out so clearly, alongside innovation. By 2021, every part of the country will be covered by integrated care systems, which will bring together local organisations, including local authorities, to redesign care and improve population health. I say to the noble Baronesses, Lady Massey of Darwen and Lady Pitkeathley, that this marks a significant change in how NHS organisations collaborate with one another and will support the health and care system to deliver a step change in how patient care is planned and delivered.
My noble friend Lord O’Shaughnessy raised the issue of primary legislation. He will be aware that the Government will consider updating legislation only where there is clear evidence that doing so would improve services for patients.
As noble Lords have noted, the spending review will have a profound impact on the prevention agenda. It will contain details of the local government funding settlement and the public health grant. As has been noted across the House, there is no time to waste in pushing forward this agenda. I say to the noble Lord, Lord Bird, that this is why prevention is a focus throughout the long-term plan. We will keep people healthy and out of hospital by focusing on the prevention of ill health and boosting services closer to home.
To address comments made by the noble Lords, Lord Rennard, Lord Turnberg and Lord Brooke of Alverthorpe, and the noble Baroness, Lady Walmsley, there is a push to improve upstream prevention of avoidable illness and its complications, such as offering NHS-funded tobacco treatment services and specialist weight management services to those with hypertension and a BMI over 30. A number of noble Lords mentioned smoking. The plan commits to offering all smokers admitted to hospital NHS-funded tobacco treatment services by 2023-24. I believe that this issue was raised by the noble Lords, Lord Rennard and Lord Turnberg, and my noble friend Lord Ribeiro.
I also note that my noble friend Lord Chadlington raised the issue of gambling and the noble Lord, Lord Brooke, mentioned gaming. We must look at those important issues in relation to health and health services. As a result of the long-term plan, within 10 years, 55,000 more people each year will survive cancer for at least five years and up to 150,000 heart attacks, strokes and dementia cases will have been prevented. In addition, we will take coherent cross-government action where required. This was demonstrated by the recent joint Defra and DHSC clean air strategy, as well as by the Government’s new world-leading plan on antimicrobial resistance, as noted by my noble friend Lady Neville-Rolfe.
The upcoming prevention Green Paper will be a major milestone in the prevention agenda this year. Our approach will also be underpinned by a focus on the reduction of health inequalities, both because it is unequivocally the right thing to do and because the potential health gains, especially in our most vulnerable communities, are significant. That was noted by the noble Baronesses, Lady Donaghy, Lady Tyler and Lady Massey. Of course, that focus will be very important.
I turn now to the plan’s commitment to improve access to primary and community healthcare services, with spending on these services increasing by £4.5 billion in five years’ time. This will allow all parts of the country to see an increase in both the capacity and the responsiveness of community and intermediate care services. As my noble friend Lady Redfern and the noble Baroness, Lady Thornton, noted, today NHS England and the British Medical Association launched the new primary care contract for GPs. The new contract framework marks some of the biggest general practice contract changes for over a decade and will be essential to delivering the ambitions set out in the NHS Long Term Plan through strong general practice services. It also includes funding for around 20,000 more health professionals in primary care networks by 2023-24. Expanding community-based multidisciplinary teams means thousands more clinical staff working in primary care and bigger teams of staff providing a wide range of care options for patients and freeing up time for GPs to focus on those with more complex needs.
My noble friend Lord Colwyn raised the important issue of dental care and NHS dentists. He is right to say that workforce planning is important in this key area. In addition, by 2023-24, every patient in England will be able to access a digital GP offer, improving access and convenience in primary care for all. Social care prescribing where appropriate, as mentioned by the noble Baroness, Lady Pitkeathley, will play a role in this.
That brings me to the important point on the safety of patient data. There are safeguards in place for this type of data, including legislation, scrutiny standards and toolkits, independent advisory bodies and a national data opt-out to ensure that data is used across the health and care system in a safe, secure and legal way. However, in response to the noble Lord, Lord Hunt, I recognise that we still have some way to go.
While I have already noted the importance of preventive care as a priority for this Government and the NHS, the plan also addresses important clinical areas and long-term conditions. Noble Lords have rightly identified that improving the early diagnosis of cancer is a priority. The new package of measures in the long-term plan include investment to support better screening services, provide new investment in state-of-the-art technology to transform the process of diagnosis and boost research and innovation. To that degree, the noble Baroness, Lady Thornton, is absolutely right.
As the noble Baronesses, Lady Masham of Ilton, Lady Gale and Lady Wheeler, identified, it is equally important that those with rare and complex conditions should receive the best support and treatment. I welcome the fact that over the next 10 years, the long-term plan will give patients better access to specialised services and offer more precise treatments. The department will continue to work with the NHS to ensure that we provide the very best service so that patient outcomes and quality of life are improved. As the NHS implements the plan, specialised services will remain a priority. That is why, every year, we invest more than £16 million in treating specialist conditions, as noted by the noble Baroness, Lady Wheeler.
I turn now to the provision of mental health services. Yesterday we had an excellent debate on this subject led by the noble Baroness, Lady Tyler of Enfield. As we know, more work days are lost to mental ill health in the form of anxiety, depression and stress than any other condition, so we have to get this right. I can reassure noble Lords that under the NHS Long Term Plan there will be a comprehensive expansion of mental health services. The plan renews the commitment to grow and invest in mental health services faster than the NHS budget overall for each of the next five years, with an additional £2.3 billion in real terms by 2023-24. This will provide a further 380,000 adults with access to psychological therapies and 345,000 more children will be able to access greater support. Crisis care will be expanded with a 24/7 community-based mental health crisis response for adults. We will ensure that that is available across England by 2020-21.
The NHS will test and roll out new waiting times to ensure rapid access to mental health services in the community over the next decade. We will reduce the number of people with learning disabilities or autism who are in-patients in mental health hospitals. It is absolutely right that we do so, and I totally support the comments made by my noble friend Lady Browning and the noble Baroness, Lady Jolly.
Specific waiting times for emergency mental health services will also take effect from 2020 for the first time, and will be set to align with the equivalent targets for emergency physical health services. This is the first time that this has happened and it is absolutely right.
I welcome the support of the noble Baroness, Lady Pitkeathley, for the NHS plan in relation to carers. Carers’ needs and views are important, and we acknowledge this.
The noble Lord, Lord Low of Dalston, raised the issue of eye care and the APPG report. I will write to the noble Lord to address this, because I am not familiar with the APPG report.
A large number of noble Lords—including my noble friend Lord Ribeiro, the noble Lords, Lord Turnberg and Lord Hunt, and the noble Baronesses, Lady Watkins and Lady Jolly—quite rightly raised workforce issues, and I want to acknowledge, as I am sure they do, the importance of our NHS workforce and all who work in it. We recognise that good leaders and leadership are essential to the provision of high-quality, sustainable services across the NHS. As part of the long-term plan, a group has been established to focus on how best to improve leadership culture and practice, talent management, leadership development and clinical leadership across the whole NHS. This work will inform the workforce implementation plan that the noble Baroness, Lady Harding, has been commissioned to produce, working closely with Sir David Behan. Initial recommendations will be presented to the department in spring 2019 and a final workforce implementation plan will follow later in the year, taking into account the outcomes of the spending review. We will go further not only to secure staff but to support the NHS in delivering its mission to become a world-class employer and to deliver the workforce the NHS needs.
A number of noble Lords raised the important issue of how we will ensure we have enough nurses, including Parkinson’s nurses. We are already taking steps, including increasing nurse training places by 25%—that is 5,000 additional training places from 2019-20. The NHS Improvement-led workforce group will agree action to improve the supply of nurses over the course of the long-term plan.
My noble friend Lord Ribeiro and the noble Lords, Lord Turnberg and Lord Rogan, will know that we have already made commitments through the next spending review period—for example, as my noble friend Lord Ribeiro said, medical training places—that acknowledge the importance of workforce training to underpin effective long-term NHS planning. At the forthcoming spending review, we will consider proposals from the NHS for a multi-year funding plan for clinical training places, based on workforce requirements in the NHS plan.
Health services are of course a devolved matter in Northern Ireland, but I will certainly convey the concerns raised by the noble Lord, Lord Rogan.
A number of noble Lords—my noble friends Lord Holmes of Richmond, Lady Neville-Rolfe and Lady Redfern, the noble Lords, Lord Hunt and Lord Scriven, and the noble Baroness, Lady Thornton—raised technology and artificial intelligence. As the Secretary of State has made clear in his vision for the future of healthcare, digital services and IT systems will need to comply with a modern technology architecture and meet a clear set of open standards so that they can talk to each other.
There have been many questions and I will shortly run out of time. However, I will write to noble Lords about the key themes that have come out in the debate and place a copy of my letter in the Library.
I did not get round to talking about technology and artificial intelligence. The Secretary of State considers this to be an important area, and I hear the concerns raised by the noble Lord, Lord Hunt.
I again place on record my thanks and appreciation for the quality and range of contributions from across the House. There is clearly much more to discuss and debate. The incoming Minister will have the opportunity to discuss these issues in greater depth with the House, including the many areas covered by the noble Baroness, Lady Thornton. We will keep the debate going.
Lord Hunt of Kings Heath
My Lords, I have a minute to wind up. It has been an excellent debate containing five key messages. First, integration of health and social care will not happen unless the Government in Whitehall integrate their strategy on policy, finance and workforce.
Secondly, this House definitely supports the priorities in the NHS 10-year plan but it must not be at the expense of core services such as oral health or eye care. I hope the noble Baroness will meet with me and the noble Lord, Lord Low, to discuss the issues he raised about ophthalmology services.
Thirdly, the Government need to be brave on public health. It is clear from speeches made today in this House that huge support will be given to tough fiscal measures.
Fourthly, this is an English plan but its challenges relate also to Scotland, Wales and Northern Ireland. I hope that the noble Lord, Lord Rogan, will be heard, because the Northern Ireland health service is going through a tough time.
Finally, carers will be asked to do even more in the future, and they must have recognition and support.
This is a good plan but the agenda is tough. I hope the Government will listen to what has been said today. I beg to move.