Wednesday 26th February 2020
(4 years, 9 months ago)
Lords ChamberNHS Funding Act 2020 View all NHS Funding Act 2020 Debates Read Hansard Text Amendment Paper: Legislative Grand Committee (England) Amendments as at 4 February 2020 - (4 Feb 2020)
Lord Bethell (Con)
My Lords, the NHS is the top priority of the British people and this Government. The NHS itself has a long-term plan to transform services in this country and to ensure that it continues to deliver world-class care for everyone while transforming itself into a sustainable service fit to face the challenges of the 21st century.
To deliver this plan, the NHS has told us how much funding it needs, and this Government are providing it—£33.9 billion extra a year by 2024. Through this Bill, we will provide the NHS with the financial certainty of a fully costed financial settlement over the next four years. Let me be clear about those numbers. This Bill will guarantee that the NHS budget will rise from £121 billion in 2019-20 to £148 billion in 2023-24.
This is the first time any Government have placed such a commitment to public services in legislation. By putting this commitment into law, the Bill removes any political uncertainty around the level of funding for the NHS. In doing so, it gives the NHS the stability it needs to plan for how to deliver the long-term plan over the next four years. This multiyear funding settlement means the NHS is no longer confined to planning on an inefficient annual cycle in which long-term interests can become obscured by short-term uncertainties about future funding.
Instead, this Bill means that the NHS can make investments now, confident that it will have the money it said it needs in future. This is better not just for patients, who will continue to get a world-class service fit for the 21st century, or for the workforce, who can focus on what they do best—delivering clinical excellence—but for taxpayers. It is not just me saying it; this is what the NHS is saying. Sir Simon Stevens said:
“we can now face the next five years with renewed certainty. This … settlement provides the funding we need to shape a long-term plan for key improvements in cancer, mental health and other critical services.”
By bringing forward this legislation, the Government are giving an ironclad guarantee to protect this NHS funding. It creates a double-lock commitment that places a legal duty on both the Secretary of State and the Treasury to uphold this minimum level of NHS revenue funding over the next four years. This point is very important: the legislation explicitly states that the Bill establishes a floor, not a ceiling, for how much we spend on our most vital and valued public service.
I will give noble Lords some examples of what this money will be spent on. The financial stability will give the NHS the space to invest in innovative technology and harness digital revolutions, to move services into the community so that people are treated in the right place at the right time, and to work together to design modern, integrated health services.
During the engagement with noble Lords, and in the other place, there was, quite rightly, significant interest in particular budget items. The area of most concern was undoubtedly mental health funding, which came up time and again. Within this financial settlement, spending on mental health will rise by an additional £2.3 billion by 2023-24, meaning it will increase faster than spending on physical health, which represents a significant step in moving towards proper parity of esteem. This historic level of investment in mental health will ensure that the Government can drive forward one of the most ambitious mental health reform programmes anywhere in Europe.
This funding will improve access to evidence-based and meaningful care for 370,000 additional adults by 2023-24. This will include, for example, adults with eating disorders, people with complex mental health difficulties who are diagnosed with personality disorders, and people with mental health rehabilitation needs.
This funding will deliver our commitment that 345,000 additional children and young people will be able to access mental health services and school-based mental health support teams by 2023-24. This will mean that by 2023-24 there will be a comprehensive offer for 0 to 25 year-olds that reaches across mental health services for children and young people and adults. Access standards for children and young people’s eating disorder services will be maintained, and there will be 24/7 mental health crisis care provision for children and young people in general hospitals and the community in every area of the country. We are not there yet, but this Government recognise that our mental health and our physical health must be seen on an equal footing. They are working hard to ensure that mental health is treated as seriously as physical health.
Let me give some other ideas of what else the funding in this Bill will deliver. It will help to create 50 million more GP appointments each year so that we can reduce the time people have to wait to see a GP. It will pay for new cancer screening programmes and faster diagnosis so that we can save the lives of 55,000 more people with cancer by 2030. It will pay for the prevention, detection and treatment of cardiovascular disease so that we can prevent 150,000 strokes and heart attacks by 2030.
This funding will help us to create more services in the community, closer to home, with pharmacies playing a much bigger role. It will allow the NHS to invest in innovative technology such as genomics and artificial intelligence, to create more precise, more personalised and more effective treatments. It will also allow the NHS to upgrade outdated technology to save time for staff and save the lives of patients. Above all, the record funding in the Bill will allow everyone in the NHS to work together to make long-term decisions about how the health system should be organised and delivered—not tied to what we have done in the past, necessarily, but driven by a clear view of what the NHS must do in the future.
Let me say a few words about funding outside the scope of the Bill. This £33.9 billion commitment is for NHS England’s revenue spending only. It is important to remember that, in addition to this funding, we have made a number of commitments that are outside the scope of the Bill, including on training and capital. On training, we made a clear commitment in our manifesto to deliver 50,000 more nurses. The latest figures show that the NHS now has a record number of registered nurses, midwives, nursing associates and nurses in training. But the truth is that we need more. We need not only the right number of nurses, but for those nurses to have the right skills, as nursing increasingly becomes a high-skilled and highly technical role.
So, from this September, we will give every student nurse a free, non-repayable training grant worth at least £5,000 each year to recruit more people into nursing. We are also expanding the routes into nursing with more nursing associates and apprentices, making it easier to become a fully registered nurse. We are also prioritising the care of our nursing staff to encourage more of them to stay in the NHS for longer. This new training package to get more nurses into the NHS is in addition to the funding contained in this Bill. We have purposefully not included training in the Bill, as the Government are working with NHS England and HEE to identify and develop a number of programmes to deliver doctors and the 50,000 new nurses. It would be premature to legislate for the cost before we have completed that work.
The NHS also needs more money for capital investment. Better NHS infrastructure is a major priority for the Government. Modern buildings with cutting-edge facilities and equipment are essential to delivering the NHS transformation we want to see over the next decade—40 new hospitals across the country, £2.7 billion for the first six hospitals alone, £850 million for 20 hospital upgrades and £450 million for new scanners and the latest AI technology. This is just to get on with those infrastructure schemes that have already been given the green light; there will be more. More capital funding will be allocated as plans are developed and costed. We do not want to include it in this Bill before the plans have been fully worked out. There will therefore be additional funding for areas that are not covered by this Bill, including public health and social care; they will be dealt with at future fiscal events.
This is unlikely to be last word on the NHS that this House will have this year. We are considering the NHS’s legislative asks around the long-term plan and will respond in due course. We will, of course, be discussing the NHS regularly in debates and Questions.
However, for now, we have this short and straightforward Bill. It can be summed up in a single word: certainty. It offers certainty to the NHS, to its 1.4 million hard-working staff and to the country—that the NHS will have the level of funding it said it needs over the next four years to deliver the long-term plan.
We have an ambitious long-term plan that will allow us not only to meet the needs of today but to rise to the challenges of tomorrow. The key to that is delivering the investment that the NHS has said that it needs to deliver the plan. That is why I am proud to commend the Bill to the House, and I beg to move.
Lord Hunt of Kings Heath (Lab)
My Lords, I am grateful to the Minister and welcome the opportunity to take part in this Second Reading debate. I declare my membership of the GMC, trusteeship of the Royal College of Ophthalmologists and presidency of GS1.
Extra funding for the NHS is always welcome. The Minister was confident that the Bill would give the NHS long-term certainty and all the money that it needs to implement the NHS plan—indeed, he said that it has been given all the money that it asked for. I just remind him that most people in the NHS understand and are clear that the amount of resources promised is nowhere near what is required. When he said that the NHS was satisfied that the money was sufficient he meant NHS England. I remind him that NHS England is a wholly owned quango accountable to him and his ministerial colleagues. The idea that it speaks for the NHS is taking quango-land fiction a little too far.
The Bill is certainly a departure—setting out the allocation to the NHS up to the 2023-24 financial year—but the suspicion is that it is little more than a political gimmick that is by no means sufficient for the needs of the NHS. There is no legal or government financial rule requirement for such legislation; it has never been done before. I am at a loss to understand why the Government have done it, because, as the Minister implied, it is quite clear that the Government will be forced during this four-year period to put more money in to shore up the deficits that will inevitably be run up by the NHS.
Our debate of two weeks ago on the performance of the NHS told its own story. Despite the heroic efforts of staff, 18.3% of people attending A&E in January spent more than four hours there from arrival to admission —the worst performance of any January since records began. The target on treatment within 18 weeks has not been met for at least four years. Other targets are missed consistently. We know that rationing is on the increase, and there are many other failings in ambulance services, mental health services and services for people with learning disabilities.
Clearly, many factors are at play in this, but when we align austerity with workforce shortages—the estimate is of a 100,000 FTE shortage at the moment—1.4 million people with an unmet social care need and a complete failure to factor in a growing elderly population, it is little wonder that the NHS is reeling under the pressure. The settlement of 3.4% growth per annum over a four-year period is certainly less than the 4% that most commentators have argued is needed—I actually think it needs more. I remind the Minister that the right reverend Prelate the Bishop of London—a former Chief Nursing Officer—said in our debate on the Queen’s Speech that the additional funding was not a bonanza and would serve only to stabilise NHS services and pay off deficits.
On deficits, NHS Providers trusts reported a combined deficit of £827 million and clinical commissioning groups a deficit of £150 million in the last financial year. The National Audit Office recently warned that trusts are becoming increasingly reliant on short-term measures, including one-off savings, to meet yearly financial targets. Clearly, many trusts in financial difficulty are increasingly relying on short-term loans from the Minister’s department, which, the NAO says in its recent report, are effectively being treated as income by these organisations, which have run up a level of unsustainable debt that reached £10.9 billion in March 2019. The NAO says that those trusts are very unlikely to meet any of that debt. Could the Minister say what is to happen to it?
The Bill is notable for what it does not include. The Minister acknowledged this. Little wonder that NHS leaders wrote to the Times at the beginning of this month, pointing out that the funding does not include areas crucial to the Government’s election promise of providing more nurses, hospitals and GP appointments. The NHS is facing a massive workforce crisis. The funding does not cover the education and training budget to help with recruitment and retention, nor does it offer any relief for public health and social care services that help keep people healthy and independent. The new migration policy announced this week, which excludes care workers as “lower-skilled”, simply adds more pressure to the social care system.
I have listened twice to the Home Office Minister’s response in your Lordships’ House. She blithely washes her hands of the problem, quoting the Migration Advisory Committee, which says that the care sector’s problem should be solved by the sector investing in making jobs in social care worth while. Have your Lordships ever heard such nonsense? How on earth, with the resources available, can the social care sector invest more in training and paying staff? At the end of this year, we will have an absolute crisis in the care sector unless, as I suspect, the Home Office is forced to reverse this ludicrous policy of excluding people coming to this country to help our care sector.
The Minister mentioned capital. The NHS was formed in 1948; 14% of its buildings are older than it is. He talked about the new hospitals. The backlog of maintenance is about £6.5 billion. The NAO produced a report that warned that the Government’s real story on capital is that in the past five years they have transferred £4.3 billion from capital to revenue to shore up the everyday finances of the NHS. The Minister is pinning his hopes on the NHS long-term plan to transform everything and make the NHS cope with the extra demand it faces. Excuse me for being a little cynical, but the NHS long-term plan is a reiteration of every plan that I have seen for the NHS in the last 30 years. It is based on the fiction that services produced outside hospitals will miraculously reduce the demand in those hospitals. Anyone who knows anything about the NHS knows that this is complete bunkum and that the Government have no chance whatever of getting anywhere near the targets that the plan produces. We will be carrying on the short-term funding crisis that we have seen over many years.
I am very glad to see the noble Lord, Lord Patel, in his place. One of the best reports on health in the last few years was that of his Select Committee on the Long-Term Sustainability of the NHS. It highlighted what he, and those working in the NHS and adult social care, described as a “culture of short-termism”, with the Minister’s department and front-line services absorbed by day-to-day struggles. Little has changed since then. I strongly support that committee’s recommendation on the establishment of an office for health and care sustainability to look at likely funding and workforce requirements up to 20 years ahead. Like the Office for Budget Responsibility, it would give authoritative advice to the public, Ministers and the NHS. Ministers would still set the budget, and answer to Parliament for it, but it would allow for a much longer-term workforce and financial plan for the NHS, taking account of the demographic pressures that we face over the next 30 years. Would it lead to more resources coming into health and social care? Nothing is certain, but it would set the context in which the country could come to a sensible decision about how much it will be prepared to pay for health and social care.
The Government’s decision to legislate with the Bill for the next four years is, on the face of it, to fund an unnecessary political gesture. Legislation clearly is not required and the Government will never be able to stick to these figures when the pressures come incessantly into the system. If, in time, it came to be a building block towards a long-term sustainable future, the Bill would be of no little significance. So far, there is precious little sign of that.
Baroness Tyler of Enfield (LD)
My Lords, I am pleased to contribute to this Second Reading debate, and—as it is my first opportunity to do so—I welcome the Minister to his new role. I look forward to working with him.
This Bill sets out the current long-term funding settlement for the NHS, as set out in the Long Term Plan published last year. While I welcome the fact that the Government have provided a long-term funding settlement to provide some of the certainty we have heard about, the key question is not whether legislation is needed—frankly, it is not necessary for the Government to commit themselves in primary legislation to something that is already well within their powers—but whether the funding allocation for NHS England increasing to £148.5 billion by 2024 is sufficient to meet a decade of NHS underfunding, to respond to an ageing population and to meet the plan’s commitments to raise standards in healthcare.
As alluded to by the noble Lord, Lord Hunt, and like many external commentators, I note that the King’s Fund, Nuffield Trust and Health Foundation have all said that an increase of at least 4% is required to modernise the NHS and improve standards. In big picture terms, the overriding concern about this Bill is that it does not apply to the whole healthcare budget. As has already been said, NHS England does not operate in isolation, and to improve the health of the population, it is essential that new funding is accompanied by equivalent and sustainable investment in public health, social care and capital funding. Failure to invest now will simply increase the strain on the NHS and store up problems for the future.
I will focus the rest of my remarks on mental health funding, which the Minister focused on in his introductory speech. It was a positive step forward that the long-term plan placed a considerably stronger focus on mental health services, with a commitment that funding for mental health services would grow at a faster rate than the overall NHS budget, increasing by at least £2.3 billion per year by 2024. That is an important figure, which I will come back to. For far too long, people with mental health problems have had to put up with second class services, with too many people struggling to access treatment and support. Decades of underfunding and neglect mean that services are too often delivered in sub-standard and sometimes dangerous facilities and buildings, and there are significant shortages in the mental health workforce.
With that as the overall context, I of course welcome the commitment that funding for mental health services will grow faster than the overall NHS budget and that funding for children’s services will increase faster than total mental health spending per se. However, we must not underestimate the challenge of ensuring that money earmarked for mental health services reaches the front line. This is the crux of the matter that I want to talk about. Although the additional funding for mental health is ring-fenced in the long-term plan, it is unclear how this will work in practice. We need much greater clarity from the Government about how they plan to guarantee that this money is spent on front-line mental health services. Frankly, it is impossible to gauge this from the data currently available. I will say a few more words about this.
During the Commons stages of the Bill, a cross-party group of MPs supported amendments to require the Secretary of State to report to Parliament every year on whether the money received by mental health services was taking us closer to achieving parity of esteem. These amendments were not accepted by the Government—sadly, from my perspective—and, as this is a money Bill, we are of course unable to table any amendments here.
I was particularly enthusiastic about the amendment tabled by my honourable friend Munira Wilson MP, which would have required the Secretary of State to lay before Parliament an annual report on spending on child and adolescent mental health services. In my view, this would have done a lot to strengthen much-needed transparency and accountability in this area. However, to try to remain positive, I noted in Hansard that the Minister replying, Edward Argar, expressed some sympathy with the sentiment behind the amendment and agreed to meet Munira Wilson and other colleagues to discuss further what could be done to improve the reporting on children’s mental health services. I look forward to hearing the outcome of that meeting and hope that the Minister in this House will make a commitment that he will report back to noble Lords on what happens in those discussions.
I want to explain briefly why I think that the CAMHS expenditure is so important. When you analyse it at a national level, it all looks pretty okay; it looks like it is going in the right direction. But this masks continued and really worrying inconsistencies in reporting by CCGs, which prevent parliamentarians and researchers being confident in the figures published at local level. For example, 34 CCGs reported spending less on services for children and young people combined, including on eating disorders services, in 2018-19 compared to the previous years, with nine of those areas having reported spending cuts of at least 27%. This is hardly in line with the public commitment to spend more in this area. I also find it baffling that CCGs which are reporting spending cuts in the dashboard are simultaneously getting a tick to say that they have met the mental health investment standard. I am really perplexed by how this is happening and, if the Minister can shed any light on this, I shall be really grateful.
Something that I have been calling for for some time now is a separate children and young people’s mental health investment standard with a dashboard, so that we can get a more detailed breakdown on the way money is being spent on services for children’s mental health, ranging from preventive to crisis care. In the same way that the mental health dashboard reports on whether each CCG has met the mental health investment standard, it should also report separately on whether each CCG has increased the proportion it is spending on children and young people’s mental health. In addition, if any CCG fails to increase the amount it spends, I really feel that it should provide a public explanation of the reason. Speaking personally, I would also like to see sanctions applied to CCGs which do not provide a satisfactory explanation.
There are a couple of other areas which I would like to cover briefly. One is the workforce. Mental health has one of the most serious workforce shortages in any part of the NHS, and securing and retaining the right workforce is probably the biggest barrier to delivering the Government’s commitments to improve mental health care. We know at the moment that, to meet the promises already made for mental health and to reduce vacancies and cover requirements, we need about 4,500 additional consultant psychiatrists for 2029.
Where are these people going to come from? The recent census by the Royal College of Psychiatrists showed that the rate of unfilled NHS consultant psychiatrist posts had doubled in the last six years and that one in 10 posts is vacant. Despite the shortage of doctors, our medical schools operate under a strict admissions cap, often turning away highly qualified and ambitious students. We need to double the number of medical school places by 2029 to train enough consultants to fill the roles already promised. I would like to see places allocated in particular to schools that have a plan in place to encourage students to choose psychiatry.
Substantial investment in expanding the workforce is urgently required and I eagerly await the publication of the NHS People Plan, which, I hope, will set out how the Government plan to address these shortages. It is vital that the Government use the opportunity of the forthcoming Budget to commit to additional investment to support the recruitment and training of mental health staff.
Finally, on capital funding—this has already been alluded to—the review of the Mental Health Act found that mental health facilities where patients are admitted are often the most out of date in the NHS estate. At times, they have more in common with prisons than hospitals. There are badly designed, dilapidated buildings with poor facilities, which all contribute to a sense of containment and make it difficult for patients to be effectively engaged in therapeutic activities. I was particularly taken with what the review said about how inappropriate it was that we still use dormitory provision in mental health wards for people who have been sectioned under the Mental Health Act. It just does not seem right at all.
The Minister alluded to the fact that the Government have taken some steps to address capital funding issues, including announcing plans to build 40 new hospitals through the health infrastructure plan. However, so far, mental health has been almost totally overlooked in these discussions, despite the review’s findings. Therefore, I again call on the Government to use the 2020 Budget to set out a major, multiyear capital investment programme to modernise the mental health estate and bring it into the 21st century.
To recap, the Government must do more to ensure that the additional funding in the Bill leads to sustained investment in mental health in every local area in England, to address the shortages in the workforce and to commit to much-needed capital investment.
Baroness Finlay of Llandaff (CB)
My Lords, I, too, congratulate the Minister on his new position and declare my interests as a past president of the BMA, a fellow of various medical royal colleges, and vice-president of Hospice UK and Marie Curie.
Yesterday, a letter went to the Prime Minister from the medical royal colleges and faculties and the Royal College of Midwives and the Royal College of Nursing, urging him to
“accept the recommendations of the report Health Equity in England: The Marmot Review 10 years on, and to go a little further.”
They announced that they
“are coming together to establish the Inequalities in Health Alliance”
and
“will be asking other organisations across the UK to join … particularly those representing social services and local authorities in all four nations.”
They went on to point out that
“The report published today by the Institute for Health Equity and commissioned by the Health Foundation, says life expectancy has stalled for the first time in at least 120 years. We are sure you know that there is a 15-20-year difference in healthy life expectancy between some of the new seats represented by the Conservatives, and others that your party has traditionally held. These disparities directly impact on NHS services, with emergency attendances doubling in the areas of lowest life expectancy.”
The letter goes on to say that it is essential that the
“government works with the devolved administrations”.
It points out that health is not in isolation and that
“earning a living wage is linked to healthy life expectancy”
and that
“Poverty has the most impact on infant and child health”
and therefore that needs to be focused on too.
The co-signatories to that letter—a full page of them—make the point clearly that looking at health in isolation is not adequate. Although we all welcome the funding that will be coming forward and the fact that it will go to the devolved nations, the problem is that it will be made on a population rather than a needs basis. The funding needs to be according to needs-based consequentials. Taking Wales as an example—I declare an interest as somebody who lives and works there—we have a population that is iller, older and poorer. It matches the north-east of England and is now reaping the disbenefit of all that happened prior to devolution, with the problems of poverty, industrial closure, and so on.
Wales, like the north-east of England, has been heavily impacted by welfare cuts. It now has protected combined spending on health and social care that is 11% higher than in England, working out at £3,051 per head of population, and there is a policy to protect social care. I urge the Minister and the Government to abandon the phrase that social care workers are “low skilled”. They are not; they are low-paid. They are very highly skilled. It is the skilled social care worker who will avoid a hospital admission and sound the alarm before a problem arises; and when it comes to people with mental health problems, learning difficulties and so, I defy anyone in this House to claim that they will be any better than a skilled care worker at managing a crisis in the community. It is very difficult work. However, there is no protected spend in the Bill for population health and, as the Minister has said, there is nothing on public health, but change will occur only through public health initiatives.
In Wales, we are tackling alcohol-related harms by bringing in minimum unit pricing on 1 March. I declare my role as chair of the Commission on Alcohol Harm. Minimum unit pricing is already in place in Scotland. We also have the Well-being of Future Generations (Wales) Act 2015 and are trying to reverse our heritage of really poor health and lack of health gains in our population. However, in Wales, as in other less wealthy parts of the UK, we have until now been quite dependent on Objective 1 funding and the European Social Fund, particularly for the third sector. That money needs to be replaced. I urge the Government to recognise that not only is there a requirement for needs-based funding but they have a duty to replace the funding that has now been lost.
As I have said, across England the royal colleges are calling for social care to immediately receive better—and, indeed, sustainable—funding. This will alleviate the pressures caused by delays in transfers to care. There is no reason why people should be discharged late in the day. There is a fair amount of evidence that if people are discharged from hospital in the morning with a care package in place, the result is a lower number of readmissions and better long-term outcomes. Other than the fact that the system is completely gummed up and log-jammed, there is certainly no excuse for discharging people to their homes in the evening or during the night without adequate care being in place. There has to be integration between the sectors at every level, with efficiency built in, and that requires a new financial settlement for social care and finding a long-term sustainable solution to providing care and support for people in England. That will probably be one of the greatest challenges for England, Wales and Scotland in the future.
Years of underfunding in social care have meant that thousands of older people have failed to receive adequate funding for their care. Delays in transfers to care will continue, resulting in the accumulating backlog arriving in A&E. As the noble Lord, Lord Hunt of Kings Heath, has pointed out, the figures for A&E are worse than ever. That is through no fault of the A&E departments at all. In December, fewer than 80% of patients were admitted, transferred or discharged within four hours. This was a record-breaking monthly low and the 53rd consecutive month that the 95% target was not met. As well as 200,000 more people waiting more than four hours to be admitted this winter compared with the same point last winter, there were nearly 200,000 waiting more than four hours in trolley beds in corridors this winter, 56,000 more than this time last year. The number of trolley waits is almost six times more than last winter. These figures alone demonstrate the logjam that exists across the whole system.
Will the Minister, having announced that this is not a ceiling, confirm that the money to go for training and workforce, the money to go specifically to public health, and other funding will continue to be distributed as well to the devolved nations? As well as it being calculated on a population basis and the old Barnett formula, there should be a needs assessment, taking into account the sophisticated data that is now available from the Marmot review and similar reviews, so that the spending is actually targeted at the areas of greatest need.
Baroness Penn (Con)
My Lords, I declare an interest as vice-chair of the Specialised Healthcare Alliance, and shall endeavour to keep my remarks—like the Bill—brief. Having been part of the process that negotiated the funding that we are legislating for today, I felt compelled to speak. It took many months to reach agreement on what was to become the longest and largest funding increase in the NHS’s history, so I wholeheartedly welcome the contents of the Bill.
I would, however, like to make two points. First, as has been said in the Chamber today and as was acknowledged at the time, the job was not finished. Understandably, perhaps, the Treasury felt considerable consternation at announcing such a large fiscal commitment outside of a formal fiscal event. Therefore, a number of items were left on the to-do list for a later date: capital; education and training budgets; public health delivery; and social care funding and reform.
The Minister said that it might be premature to include those in this Bill, but I say to him gently that we have had several formal fiscal events since this spending was announced over 18 months ago. There have been welcome steps in these areas, but ultimately they remain unresolved. I will not ask the Minister to preview what is in next month’s Budget or the spending review later this year but I hope that the Government will use them as an opportunity to provide for long-term, multiyear commitments in these outstanding areas. If they do not, we will continue to face situations such as with the public health grant allocation, where providers do not know their financial position, with just over a month to go before the start of the financial year. Can the Minister tell the House when the allocations for that grant will be confirmed? Only if we invest in prevention, capital and workforce on a long-term basis will we create the capacity in the system for the extra money in this Bill to actually improve services and outcomes for patients.
The second area I wanted to touch on is mental health. During the discussions about the funding settlement provided for in the Bill, I had a specific aim: to ensure that the money and the long-term plan that accompanied it reflected in a meaningful way the priority the Government gave to improving mental health services. Too often the refrain on mental health was that, while all the work across different government departments and across society, from tackling stigma to improving workplaces and schools, was welcome, it would not shift the dial while mental health services were underfunded and overpressured.
I do not pretend that the funding we are voting on today solves that problem, but there were two important steps in the right direction, as has already been noted: first, that mental health funding would increase as a proportion of overall health funding in each and every year, and secondly, and importantly, that this commitment would be traceable and auditable. Alongside that funding, though, the Government committed to reform and in particular to updating the Mental Health Act, which dates back to 1983. Although I support the Bill, it is also, as the House of Lords Library politely puts it,
“an example of the Government committing in primary legislation to an action which is already within its power.”
In contrast, there are few areas of legislation that so directly impact the lives of individuals as the Mental Health Act, and it is overdue for reform. I therefore hope the Minister is able to reassure me that the time spent on this Bill has not been at the expense of producing the White Paper and drafting the legislation needed to implement the recommendations in Sir Simon Wessely’s excellent review of the Mental Health Act.
I was pleased to receive a Written Answer from the former Minister. I took heart that the White Paper would be published not merely “in due course” but in the next few months, although I am not sure where that sits in the hierarchy of government timings compared with “shortly”. If I am able to tempt the Minister to go even further today and specify a month by which we can expect that White Paper to appear, my support for the Bill will be even more fulsome than it already is.
Lord Kakkar (CB)
My Lords, I join in congratulating the Minister on the way in which he has introduced this Second Reading. Clearly it is to be welcomed that there is clarity on the financial settlement attending the delivery of the NHS in England over the years remaining in this Parliament. I declare my interest as chairman of UCLPartners and chairman of the King’s Fund.
This is not the first time that a Government have committed substantial additional funding for the delivery of the NHS. On previous occasions when these commitments have been made, the regrettable fact has been that the performance associated with the additional funding has been uneven. This demonstrates that additional funding in itself is not the absolute answer to all the issues that face the long-term sustainability of the NHS.
Clearly, additional funding is critical; as we have already heard in this debate, the funding that has currently been guaranteed will play an important role in ensuring the medium-term sustainability of the delivery of important services. However, the reality is that one must be certain that the environment—the structural solution for the NHS to which this additional funding is going to be delivered—is entirely appropriate. The noble Lord, Lord Hunt of Kings Heath, has identified that the long-term plan in itself identifies a number of opportunities by which sustainability for the NHS can be achieved.
Much of the long-term plan is predicated on the concept that integrated care is now essential if the delivery of health services is to be sustainable. The NHS long-term plan identifies three important integrations: between primary and secondary care; between physical and mental healthcare; and between healthcare and social care. In providing the long-term plan, the NHS has also made suggestions with regard to legislative change that might be required to ensure that the disposition of the additional funding, and indeed the delivery of the plan itself, is going to be improved. I know the Government have received those legislative suggestions, but they have yet to respond to them. In opening the debate, the Minister made reference to that and to the fact that further legislation may come before your Lordships’ House in due course in this Parliament to deal with those questions.
One important suggestion is of course a merger of NHS England and NHS Improvement. I wonder whether Her Majesty’s Government have found themselves in a position to take a view on that matter. Clearly it is at the heart of whether the system for the delivery of healthcare is as effectively constructed as it needs to be to ensure that this vital additional funding is applied in the most effective and efficient fashion.
Additionally, suggestions have been made that commissioners and providers may come together in joint decision-making committees such that, at a local level, the disposition of this additional funding is applied in such a way that the integration of services is achieved effectively and that this funding provides maximum benefit, both in individual patient care and the management of local populations. Do Her Majesty’s Government believe that joint decision-making committees, created on a voluntary basis, will have sufficient influence and power at a local level to drive forward the appropriate integration of services such that the delivery of care achieves the benefits that we very much hope will be available to patients and to local populations?
The noble Lord, Lord Hunt of Kings Heath, made another very important observation earlier, which relates to the report on the long-term sustainability of health and social care from your Lordships’ ad hoc committee chaired by my noble friend Lord Patel. It is a very important observation that this Bill, which is laying out in statute guaranteed funding for the NHS over multiple years for the first time, could form the basis—the foundation—for a first step towards that broader, long-term sustainability for the NHS. Your Lordships’ committee report made a number of important recommendations. Some of those have already been adopted by Her Majesty’s Government in a number of different ways, so clearly that report has had impact and is influential in the debate with regard to the long-term sustainability of the NHS. It should be taken as a very important observation that the presentation to this Parliament of this Bill in itself is important but could provide for a longer-term approach to the sustainability of the NHS, dealing not only with financial questions, as this Bill does, but with the important structural issues that will need to be addressed if repeated increases in funding can be applied in the most effective fashion to achieve the goals and objectives that we all strongly support.
Lord Bradley (Lab)
My Lords, I begin by declaring my health interests as given in the register. I would like to contribute to this Second Reading debate by discussing NHS funding and by raising, in particular, the crucial issue of mental health and other complex needs funding, which the Minister and other noble Lords have recognised.
During the debate on the Queen’s Speech, I suggested that, as well as enshrining
“in law the National Health Service’s multiyear funding settlement”,
it would
“also be appropriate to enshrine in law the commitment to achieve parity of esteem and equality of access between mental health and physical health expenditure over the same funding period, rather than merely retaining it as an aspiration in the NHS mandate”.—[Official Report, 9/1/20; col. 384.]
Clearly, this suggestion found no favour with the Government, but it is worth making the case again today for significant additional investment in mental health and related needs.
Let us consider some of the reasons why this is so important—for example, children and adolescent mental health services, or CAMHS. Currently, on average, children and young people visit their GP three times before they get a referral for a specialist assessment, and then have to wait more than six months for treatment to start. Children are reaching crisis point before getting the support they need, and the number of children attending accident and emergency departments because of their mental health, in a situation of crisis, is increasing year on year. Similarly, suicidal children as young as 12 are having to wait more than two weeks for beds in mental health units to start their treatment, despite the risk to their own lives.
As Justin Madders MP, our health spokesperson in the other place, identified in the Commons debate on this Bill, three out of four children with mental health conditions do not get the support they need. Over 130,000 referrals to specialist services are turned down because, as demand increases, thresholds for access to care rise. Appallingly, 400,000 children and young people with mental health conditions are not receiving any professional help at all. We know that mental health conditions in adults often begin in childhood, so the failure to adequately invest in CAMHS will end up costing the NHS far more in the long run.
We know that mental health represents about 23% of the total disease burden on the NHS, but a mere 11% of the NHS budget is spent on mental health; and only 15% of that 11% is spent on child and adolescent services. It is clearly welcome that the NHS long-term plan made a specific commitment to add a further £2.3 billion to the mental health budget by 2023-24, but as the Institute for Public Policy Research has pointed out, to achieve parity of esteem for mental health services, funding for those services needs to grow by 5.5% on average over the next decade. The NHS planned to spend £12.2 billion on mental health funding in 2019, but the IPPR estimates that this needs to reach £16.1 billion in 2023-24 and £23.9 billion in 2030-31. So, what is the Minister’s view on this apparent huge shortfall in investment in the mental health budget?
Of course, not all mental health and related services are funded by the NHS. As the Centre for Mental Health has noted, significant elements of mental health support for people of all ages come from outside the NHS, predominantly through local government. The largest part of this derives from adult social care, but there are important contributions from public health—for example, drug and alcohol services, suicide prevention and smoking cessation programmes. While it is accepted that NHS funding is projected to rise over the next five years, social care has only one year’s funding agreed to date, and public health services are yet to receive information on next year’s public health grant. This will clearly exacerbate the severe problems in a wide range of support services for people with many complex needs. Do the Government recognise the fragility of this situation and will they announce a robust funding settlement for social care in the Budget in two weeks’ time?
This fragility is further evidenced by the state of the workforce, as we have heard. There were a staggering 8,000 mental health nursing vacancies in England in the third quarter of 2018-19, with vacancies continuing to rise. One in 10 consultant psychiatric posts is vacant, as we have heard, rising to a dreadful one in six in child and adolescent mental health services, according to the Royal College of Psychiatrists. These figures underline the huge challenge to recruit the nurses to meet the massive needs and demands of the service. I welcome the decision to offer maintenance grants to people in nurse training from September. This will help to attract applicants, but universities such as Salford, where I am pro-chancellor, and NHS employers will still struggle to recruit, train and, crucially, retain the large numbers of additional mental health staff required over the next five years, especially, as we have heard, after the end of the transition period following exit from the European Union. The Prime Minister has committed to recruiting 50,000 more nurses across the NHS, so can the Minister confirm today how many of those will be specifically for mental health and related services?
I have two further points. The first is about speech and language therapy. From my work with the development and rollout of liaison and diversion services, and given that core services now cover 100% of the country, I recognise the value of speech and language therapists. I certainly hope that, with the additional NHS investment, they will form a key part of the further enhancement of liaison and diversion services. More generally, as the Royal College of Speech and Language Therapists has made clear, it is hoped that, alongside reform proposals in the NHS long-term plan, this Bill will help to ensure the provision of adequate services for people with communication difficulties and swallowing needs. As it points out, there are many such people in the United Kingdom. In fact, 20% of the adult population experience communication difficulties at some point in their lives, and more than 10% of children and young people have long-term communication needs.
In areas of social disadvantage, around 50% of children start school with delayed language and other identified communication needs. People with a range of conditions will also have swallowing needs. These include people who have had a stroke and those who live with various cancers or neurological conditions, such as dementia, Parkinson’s disease, multiple sclerosis and motor neurone disease, as well as those with learning disabilities and mental health problems. It is clear that speech and language therapists play a crucial role in supporting these people, their families, friends and carers, and the other professionals who work alongside them. It is therefore essential that the appropriate level of speech and language therapy be commissioned out of the extra funding in this Bill, so that those people’s needs are identified and met.
Finally, on capital funding, as we have heard, this Bill enshrines in law only revenue funding, but huge amounts of capital are required to address such major problems as maintenance and repair backlogs in the NHS estate and replacement of out-of-date equipment. The Government have committed to 40 new hospitals but amazingly, only six of these have been given the green light to proceed. One of the remaining 34 schemes —which I understand is “oven ready”—is North Manchester General Hospital, now part of the Manchester NHS hospital trust, in whose area I live. This hospital rebuild is desperately needed to meet the huge healthcare needs of the population of that area. When the Minister responds, will he tell me exactly when this hospital development will finally be given the green light to proceed as the seventh of the Government’s 40 committed schemes? Will he also give me the assurance I seek that the investment identified in this Bill will genuinely lead to parity of esteem and equality of access for some of the most vulnerable people in the country, who are suffering mental health conditions or have other serious complex needs?
Lord Low of Dalston (CB)
My Lords, the Bill commits the Government to increase funding for the NHS by £33.9 billion in cash terms by 2023-24, with NHS England spending increasing to £148.5 billion by 2024. This is the first time that a multiyear funding settlement for the NHS has been enshrined in law. It also provides a long-term settlement to underpin the commitments set out in the NHS Long Term Plan. This is an important element of the Government’s programme and should clearly be supported. But, while the additional funding for the NHS is to be welcomed, this will be adequate only if social care is also properly funded. If funding for social care is inadequate, knock-on effects impacting on the health service will be felt. Indeed, the NHS Long Term Plan clearly states that
“the wellbeing of older people and the pressures on the NHS are … linked to how well social care is functioning.”
When agreeing the NHS funding settlement, the Government therefore committed to ensuring that adult social care funding is such that it does not impose additional pressure on the NHS over the next five years. While the additional £1.5 billion promised for social care in the recent spending round for 2020-21 is welcome, this is the minimum needed to keep the adult social care system afloat this year. Indeed, it is questionable whether it is even that. Not all this funding is guaranteed for adult social care. Local authority funding has not kept pace with demographic pressures. Indeed, cuts in local authority funding have been a principal focus for cuts in public expenditure.
Looking ahead, there is a large funding gap to be bridged if the system is to be improved on a sustainable basis. Only last year, the House of Lords Economic Affairs Committee estimated that improving care quality and addressing unmet need alone would require an additional £8.1 billion in 2020-21. Without specific commitments to fixing the crisis in social care, spending on the NHS will be severely undermined. There is thus strong support for an amendment to the Bill requiring the Secretary of State to report annually on whether the allocation to adult social care is enough to avoid negative impacts on the NHS. As it is, following a decade of underfunding, the commitment in the Bill falls short of what is needed to respond to an ageing population and drive NHS standards up. The increase is 3.3%, despite the King’s Fund, the Nuffield Trust and the Health Foundation all stating that an increase of at least 4% is required to modernise the NHS and improve standards.
Age UK has two key concerns regarding the Bill. The first is that it does not apply to the whole of the healthcare budget. NHS England does not operate in isolation, and to improve the health of the population it is essential that new funding is accompanied by equivalent and sustainable investment in public health, social care and capital. Failing to invest now will increase the strain on the NHS and store up problems for the future. The second concern is that unless robust commitments are made to investment in the workforce, the funding provided in the Bill will be similarly undermined.
When it comes to improving population health, prevention is better than cure. Analysis by the Centre for Health Economics has found that spending on the public health grant is up to four times more cost effective than spending on the NHS. By investing in preventive services, it is possible to decrease the incidence of many common conditions that affect people in later life and reduce the burden on the NHS. The broken social care system harms everyone, not just those with an unmet need for social care. Delayed discharges from hospital due to a lack of social care costs our NHS an eye-watering £500 every minute. To help the NHS, the Government must secure the immediate future of care by investing to shore up the broken system and by setting out a long-term, sustainable solution.
Despite the importance of prevention, public health grant funding for prevention services from this April has not yet been announced. This means that providers are unable to plan, and some are even having to put staff on notice of redundancy as they are unsure whether contracts will be renewed. This uncertainty comes on top of historical funding cuts. Funding to local authorities for the public health grant has been cut by £700 million in real terms between 2015-16 and 2019-20, putting essential services for older people at risk. Areas with the greatest need have been worst hit, as was confirmed by Sir Michael Marmot just yesterday. Cuts to the public health grant have been six times larger in the poorest areas than in the wealthiest. Meanwhile, the 10 most deprived areas have shouldered 15% of the reductions to the public health grant. These cuts risk exacerbating the difference in healthy life expectancy between people living in the most affluent and those living in the most deprived areas, which already stands at 19 years. They also place the Government’s grand challenge on healthy ageing, which aims to improve healthy life expectancy by five years and reduce health inequalities, at significant risk.
If we want to improve public health, investment in the NHS alone is not sufficient. The Government must provide sustainable funding to the public health grant and develop a comprehensive strategy that lays out how it will improve public health for older people. It will additionally not be possible to fulfil the commitments laid out in the NHS Long Term Plan or make the most of the new funding provided by the Bill without urgent investment in the workforce. One in 11 vacancies in the NHS is currently unfilled. Last year, £5.5 billion was spent on temporary staff to cover vacancies and other short-term absences. If current trends continue, there will be a shortfall of 250,000 staff in the NHS by 2030.
Lord Willis of Knaresborough (LD)
My Lords, I shall start my brief contribution on a positive note about the Bill. It is the first time for a considerable number of years that we have a Government who recognise that the NHS requires both additional and stable funding. That is something that the whole House should welcome.
However, the Bill is designed mainly for a political audience. It is certainly not the comprehensive framework for funding a world-class, integrated, 21st-century healthcare system that many across the Chamber would have liked to see. If it had been, it would have reflected the House of Lords report, The Long-term Sustainability of the NHS and Adult Social Care which has been mentioned on a number of occasions; four of us in the Chamber were members of the superb committee of the noble Lord, Lord Patel. Its report was a fundamental look at the way in which we should look for an integrated system, rather than try to find little ad hoc solutions.
The NHS does not, as the Bill implies, operate in a silo but is impacted by other interdependent factors, as many Peers have said. Capital adult social care costs, the challenge of educating and training a workforce and the application of ground-breaking technologies are just a number of the factors that determine health outcomes but do not feature in the Bill. As the Secretary of State and the Minister rightly said, this is only a floor, not a ceiling. They have also said that other proposals are afoot to deal with some of those issues, and we await with interest their arrival. However, having listened to a number of desperate pleas—and they are desperate pleas—about the future of mental health services, I will caution the House. Simply believing that we can add X number of mental health nurses, psychiatrists or consultants just like that is absolute nonsense. We need a totally different, radical approach to how we staff our health and care services.
I digress slightly, but 18 months ago I did a report for Health Education England on the mental health workforce in the future, 10 years ahead. I looked in particular at psychiatrists and psychologists and found that our universities are producing about 150,000 graduates a year with a psychology qualification. We produce 1,500 people with a psychology PhD, and about 3% of them go into the health service—yet we have spent all that money training them. When we ask, “Why don’t you—?”, the response is, “I’m sorry, that’s a different department. We can’t do that.” If the Minister takes nothing else from my speech, I urge him to think outside the box on this.
My main purpose in speaking in this debate is to raise an issue that has not been raised by others: medical research in the NHS, which is absolutely fundamental to 21st-century healthcare. I accept that Governments of all persuasions, from the Labour Government in 2006 and the Cooksey report right through to the current Government, have increasingly spent resources on health research. I declare interests as the chair of the Yorkshire and Humber Applied Research Collaboration and of the national Genomics Education Programme, and acknowledge my recent chairmanship of the Association of Medical Research Charities.
This Bill, with its provisions for stable, long-term funding increases, is an opportune moment for us to look at the potential of embedding research into the very fabric of the NHS, as intended by the Health and Social Care Act 2012. The amendment from the noble Lord, Lord Patel, said research should be a fundamental element of all activities in the NHS, yet that seems to have gone by the way.
I am delighted that we are getting a commitment of £33.9 billion a year by 2024. Whether it needs to be in legislation is doubtful, but I like that commitment. However, it goes nowhere to meeting the Government’s own contribution—pledged under Prime Minister May —to the long-term plan. The long-term plan committed to playing its full part in helping patients and the UK economy realise the benefits of research, as laid out in the Government’s Life Sciences Industrial Strategy. It also committed to incorporating key actions from the life sciences sector deals to make research and innovation one of the central drivers for progressing care quality and outcomes. Improving health outcomes for patients and the public will not be realised without further research and innovation. The pipeline of innovation is dependent on research taking place upstream as well as at the bedside.
Recognising the potential of research to lead to earlier diagnoses, more effective treatments and faster recoveries, the long-term plan—for all its faults, and I accept the very strident comment from the noble Lord, Lord Hunt, that every Government over the last 40 or 50 years have contributed to this—made a range of specific commitments: for example, to increase public participation in research and to sequence the genomes of 500,000 individuals by 2024. The latter offers particular hope for those with rare genetic conditions and opens a door to individualised, personalised medicine.
By embedding research, trusts can make even more progress in improving patient care and outcomes by implementing interventions that research has shown to be effective and decommissioning those that have proven ineffective. Taking out those things that do not work is an equally effective way of not only delivering high-quality care but tailoring it specifically to patient needs.
Patients and the public tell us that they want opportunities to be involved in research. Some 77% of those involved in Wellcome’s public attitudes survey last year said that they wanted their medical records to be used for medical research. Studies also suggest that engagement in research improves the job satisfaction of healthcare professionals, which in turn boosts morale, helps reduce burnout, improves retention and has direct implications on the heavy financial pressures on many hospital trusts.
By research, I do not necessarily mean pointy-headed people in white coats. Research is now conducted by midwives, nurses, pharmacists, primary care and public health practitioners, medical associate professionals, allied health professionals and others. In the nursing standards, which we completed only 18 months ago, it is now a requirement for student nurses to be involved in research methods as part of their undergraduate training. The people who work with patients on a day-to-day basis, by their bedside, are the best people to spot things that need improvement.
For research to take place, sustainability of funding is required. Industry and charities are willing to contribute—and do so—but it requires the taxpayer to take the lead, and this is not always the case at present. This gives me an opportunity to commend to the House the work of the charitable sector, in particular AMRC, its umbrella champion chaired by my noble friend Lord Sharkey. In 2017-18, AMRC members, which include the Wellcome Trust, the British Heart Foundation and other major charities, contributed £1.4 billion to medical research in the UK. Some 31% of non-commercial research in the NHS—more than is contributed by the Medical Research Council or the NIHR—comes from the charitable sector. In the same year, charities recruited over 200,000 people into more than 1,300 clinical studies.
The prize for translating research into patient outcomes is huge. Today, the UK is regarded as world leading in translating research dollars into health outcomes, and this must be supported and mainstreamed. The opportunity that health research brings to lower costs and to produce satisfaction for professionals working in the service and better patient outcomes is clearly a no-brainer and ought to be part and parcel of this settlement, so we are not left waiting for some fictional figure which might arrive down the road.
Lord Warner (CB)
My Lords, I found this Bill slightly bizarre. I have been around government for about 50 years and I have never seen a Government come to Parliament and ask it to direct two government departments to lay particular estimates four financial years ahead. That is a rather unusual practice, so I start from the same position of incredulity as the noble Lord, Lord Hunt of Kings Heath. We ex-Health Ministers tend to be a sceptical set of fellows.
The figures in the Bill have a spurious precision, given that they are based on a cash figure for 2024 that was agreed with NHS England only—nobody else—in the autumn of 2018. I will come back to the issue of inflation-proofing.
There are many legitimate questions that we ought to be able to ask as part of scrutinising this unusual Bill—questions of interest to patients, taxpayers and the NHS itself. But I am told by the clerks that, because the Speaker of the Commons has labelled this a money Bill, we cannot do this through amendments at Committee or other stages. All we can today is pose some questions drawing on the excellent briefing provided by the BMA, NHS Providers, Mind and others. I also support the gentle chiding of the Minister by the noble Baroness, Lady Penn. I hope that does not get her into trouble with her Front Bench.
First, the sums set out in the Bill are 2018 cash figures with no provision for inflation-proofing. Do the Government really think there will be no inflation over the next four years, or will our old friend “improved efficiency” be brought in at some point to balance the books? Perhaps the Minister could explain why the Bill includes no provision for inflation-proofing the cash figures?
Secondly, as the Minister acknowledged, the figures make no provision for capital expenditure. Where is the money for the Prime Minister’s 40 new hospitals or the 20 hospital upgrades promised last summer? When will the NHS capital budgets for these four years be made public? Why are they not set out in the Bill? Why are there no figures at all on capital in the Bill, or is there really no agreed capital budget for the NHS 10-year plan? In my experience, new hospitals usually have additional revenue costs, so can the Minister say whether the revenue figures in this Bill cover the extra revenue that will arise from the capital programmes for new and upgraded hospitals?
Thirdly, the Government’s immediate two predecessors had a poor track record on protecting capital expenditure, as the National Audit Office has pointed out. Between 2014-15 and 2018-19, £4.3 billion was transferred from the capital budget to revenue with the result that there is now a maintenance backlog of £6.5 billion. Will the Minister clarify whether the maintenance backlog, in whole or in part, is to be funded from the revenue figures in the Bill?
Fourthly, what is to happen to the so-called short-term loans that the department has made to NHS trusts in financial difficulty? The NAO has said that such loans stood at £10.9 billion at March 2019. If they had to pay back the loans, some of the trusts would be insolvent. Will trusts with loans be required to pay them back, in whole or in part, from the revenue funds in the Bill, or will the Government write off the loans or reschedule them over a longer period than that covered by the Bill? Will new loans be available to trusts which get into financial difficulty during the period covered by the Bill?
Fifthly, as the Minister acknowledged and others have mentioned, there is no provision in the Bill’s figures for public health—an area that has consistently had its funding cut over the past decade. Michael Marmot has repeatedly shown that austerity has halted rising longevity and that health inequalities have increased over the past decade in deprived areas, especially among women. When will we know the matching revenue figures for public health and whether they can be agreed on a multiyear basis?
Sixthly—there are not many more—can we be confident that a lot of this new NHS revenue money will not be spent on keeping elderly people unnecessarily longer in expensive acute hospitals because of a decade’s, and continuing, scandalous neglect of adult social care services by a succession of Governments? Over the period covered by this Bill, we know from work done by the Institute for Fiscal Studies that, on present plans, there is likely to be a real-terms gap in adult social care funding compared with service levels in 2010 of about £8 billion. Will the Government plug this historic gap alongside any new funding system for adult social care? If they do not, the NHS will continue to pick up some of the tab for underfunded social care from the extra revenue funding in this Bill. If the Minister cannot answer my questions today, I should be grateful if he wrote to me, because it would save me putting down Parliamentary Questions.
This Bill has more holes in it than a Swiss cheese, but I will resist the temptation to identify more. However, I want to ensure that there is government and NHS accountability for showing the spending increases for areas of service that have historically been neglected. I describe these as Cinderella services, such as mental health, community health, public health and children’s services. I would have liked to move amendments requiring Ministers to report to Parliament every six months on the spending and staffing progress in these historically neglected areas. Alas, that is not possible, but how will Parliament be kept informed of progress in these neglected areas? If we do not tackle them better than we have in the past, the NHS long-term plan simply will fail.
Finally, I want to raise the issue of whether the funding in this Bill will deliver the first part of the 10-year plan. In my time as a Health Minister, between 2003 and 2007, we were increasing NHS revenue spending by at least 6% a year to make good the historical neglect of the NHS in the 1990s. That rate of increase was pretty generous and could not be sustained, but if you neglect institutions such as the NHS for a long period and do not make good their historical neglect with a spurt of generosity, you will fail to put them back on an even keel. The figures in this Bill provide cash increases of little over 3% a year after a decade of neglect. This is almost certainly not enough to repair the damage and deliver the NHS sustainability set out in The Long-term Sustainability of the NHS and Adult Social Care, which others have mentioned, the report by a Select Committee of this House of which I was proud to be a member.
I fear that the Government are deluding themselves, the public and the NHS if they think that the funding proposed in this Bill is anything like adequate to fix the damage done to the NHS over the past decade.
Lord Young of Norwood Green (Lab)
My Lords, I was going to welcome the long-term funding, but now that my noble friends have suggested I should be cynical, sceptical or chiding, perhaps I will tone down that enthusiasm. Nevertheless, I want to comment on the commitment to build 40 new hospitals. I hope that, regarding the procurement contract, the Minister can assure us that we have learned lessons from the Carillion failure. If not, there could be more disasters in the making.
The Library briefing document states that Mr Hancock stressed that the sums in the Bill were
“the minimum levels of funding, but actual spending could be more: he said they would ‘set a floor, but not a ceiling.’ He then listed some of the services which would be provided with the additional funds”.
I noted the reference to “more GP appointments” and thought that was to be welcomed, but the challenge, as a number of noble Lords have said, is whether we can recruit and train the new doctors and retain the doctors we have. The early retirements are a worrying indicator.
I welcome the Minister’s point about restoring the nurses training bursary. One might question why we took it away in the first place, given the huge number of vacancies, and what I regard as the shame of continually having to poach both nurses and doctors from overseas countries that badly need them too.
In talking about building new hospitals, perhaps the Minister can say something about the state of many GP surgeries, which require investment. If they do not get it, they cannot provide the additional service needed, which puts further strain on A&E. In a previous debate, I cited the problem my own local practice had. Here, I should declare an interest as a member of the patient care committee. New hospitals have to be staffed, as do existing ones. The figures have been quoted; I do not want to go over them again. However, I do want to refer—unsurprisingly, as an apprenticeship ambassador—to a couple of briefings I have received. One is from Unison, which quotes some interesting stats. It did a survey and 54% of trusts found that 80% of the money paid into the apprenticeship levy
“was unspent as at May 2019. For these trusts alone, that amounted to £200 million of unspent funds.”
Those funds are starting to expire and if they are not spent in the two-year period, they go back into the system—to the Treasury, at worst—or they may be invested in other apprenticeship levies. It is worrying because of the huge number of vacancies in the NHS, and because the Government have said that 5,000 of the 50,000 more nurses they promised by 2023-24 will come from degree apprenticeships.
I suggest to the Minister—I do not wish to convey only bad news—that there is an example of good practice. A briefing from NHS England described an interesting collaborative approach, involving three trusts in the Gloucestershire area, to recruiting and procuring assistant practitioner apprenticeships. They had different requirements—people for mental health care, for acute care and for community care; all vitally important. By working collaboratively, they have made significant use of the apprenticeship levy. My plea to the Minister is that he should try to spread best practice. That will be a continuing theme of my contribution today.
The Library briefing mentioned an issue which the Secretary of State has committed to and which has already been referred to by the noble Lord, Lord Willis: investments in innovative technology. The NHS’s record in introducing new technology is not good. As I have mentioned in a previous debate, when I spoke to a registrar in an A&E department, he protested that he still cannot electronically transfer patient notes from one hospital to another. One starts to despair—we are talking about much more advanced innovative practice, but we still have not mastered some of the basics. So there are some easy hits in that regard.
I concur with my noble friend Lord Bradley on the issue of children’s mental health. I should declare a personal interest—I have a granddaughter who needs a lot of care. Her family have had to wait a long time to get anything at all, which has had an impact on them. It is not just about the huge impact the child, their education and future; it is the family who must struggle with the repercussions. This underlines the importance of spending on mental health, which a number of noble Lords have referred to.
My next point was covered by the noble Lord, Lord Warner. We might argue with the noble Baroness, Lady Penn, about who has spent most. That the previous Labour Government did spend a huge amount of money is a legitimate point to make. We reduced waiting lists and made some significant improvements. I do not want to carp about it, except to say that one thing everyone in your Lordships’ House can agree on is that, when we are spending these large sums of money, we want to get the best bang for our buck, to use that cliché.
I was really interested in a comment made, I think, by the noble Lord, Lord Willis. I had never thought about the role of all NHS staff in providing research. He made a really interesting point. There is a lot of knowledge, experience and good practice out there, which needs to be considered if you are going to spend these significant sums of money. Can the Minister say how the Government are going to spread best practice? Have they adopted this as a necessary strategy? I wish them well, because the view that we need this to succeed for the future of the National Health Service crosses all boundaries in this House.
Baroness Hollins (CB)
My Lords, I remind the House of my presidency of the Royal College of Occupational Therapists, and my other interests in the register. The Royal College of Occupational Therapists and several other charities have published the Community Rehabilitation: Live Well for Longer report and are calling for improved community rehabilitation for everyone who needs it. I was therefore very pleased that the Minister spoke of the Government’s commitment to treat people in the right place at the right time, with investment being made in integrated care locally. This is essential to improve rehabilitation for both physical and mental health long-term conditions and to avoid unnecessary admissions.
One area of the NHS funding settlement that has been widely welcomed is the commitment to increase overall spending on mental health by at least £2.3 billion by 2023-24. I will focus my remarks on this area. This is backed up by a commitment that every local clinical commissioning group will increase the amount it spends on mental health every year. As a psychiatrist, of course I welcome this increase in spending on mental health. However, as a specialist in learning disability, I am concerned that there seems to be no similar commitment to increase funding for helping this group of patients or for research in this area.
The Government announced that they spent £12.5 billion on combined mental health, dementia and learning disability services in England in 2018-19. However, the commitment to increase year-on-year spend seems to apply only to mental health. Could the Minister clarify this? In fact, it is impossible to know how much local areas are spending on dementia and learning disability because they publish only combined figures. I would welcome some guidance on the action being taken to ensure investment in learning disability and dementia. We cannot see the breakdown, but we know that NHS England has access to more detailed figures. Every CCG is audited by NHS England to make sure it has met the mental health investment standard—the rule that says that each CCG must increase how much it spends on mental health every year. Here is the conundrum.
The Royal College of Psychiatrists provided a helpful briefing for this Second Reading and highlighted that all 195 CCGs were confirmed as having met the mental health investment standard. That sounds really good, but is it not then rather confusing to learn that, last year, 32 CCGs—16.4% of the total number—reported that they had reduced how much they spent on combined mental health, learning disability and dementia services? I emphasise that every one was told that it had met the mental health investment standard. It appears that they must have achieved this by significantly cutting how much they spent on learning disability and dementia. Could the Minister confirm whether this is the case, or whether there is any other reason for a cut in overall spending?
The long-term plan commits the NHS to increasing investment in intensive, crisis and forensic community support for people with a learning disability and to take action to tackle the causes of morbidity and preventable deaths in people with a learning disability and autistic people. I declare my chairmanship of the oversight panel to review the care of people in this group, who are being detained in segregation under the Mental Health Act, often because of a lack of integrated community services.
The Royal College of Psychiatrists has called on the Government to require every CCG to publish a detailed breakdown of how much it spends on each of mental health, learning disability and dementia services so that the public can have a better understanding of what is happening. Will the Minister agree to look into to this? I particularly appreciated the comments of the noble Lord, Lord Willis, about the number of psychology graduates and simply comment that much more could and must be done to enable these graduates to get the further training they need to be able to work in healthcare.
Baroness Brinton (LD)
My Lords, I thank the noble Baroness, Lady Blackwood—the predecessor of the noble Lord, Lord Bethell—and the honourable Edward Argar for the helpful meeting we had just before Recess to discuss the Bill. I also extend my thanks to the noble Baroness, Lady Blackwood, for her services as Health Minister to this House. She will be sorely missed. I congratulate the noble Lord on continuing in this role.
I echo the thanks that other noble Lords have expressed to all the organisations which have sent us excellent briefings. Given that this is a Bill of one and a half pages, we have received probably a few telephone directories’—if they still existed—worth of briefings. It has been fascinating to hear the debate in your Lordships’ House today and to hear the same themes again and again from all sides of the House.
The Liberal Democrats will not oppose the Bill, although, we believe that, along with many others, it is not the panacea to health and social care that both the Prime Minister and Matt Hancock have been leading people to believe. I point out that the Bill does not seem to take account of any Barnett consequentials or social inequality issues, as has been raised by noble Lords. I hope that the Minister will be able to reassure the House that if there is extra funding for England, that should also be reflected in the devolved countries. There really needs to be a redistribution in terms of need as well. We absolutely understand that that has gone badly wrong in recent years.
Other noble Lords have already given a great deal of evidence on the current financial crises faced by different parts of the NHS, but it is worth briefly reiterating some of the headlines. We have heard that the revenue will increase from £120 billion in this financial year to £127 billion for the year we are about to start, and then increase further to £148.5 billion in 2023-24. Last year, NHS England’s long-term plan set out how it will deliver services over the next decade. I think I probably was not alone, when I read that plan last year, in thinking, “My goodness, they certainly know to squeeze every last penny out of the NHS to try to deliver those services.” We see what is happening at the moment with the pressures on the NHS. It is struggling—for the very good reason that this funding is not enough.
Others have argued that there is no need for this Bill at all as there is no need to enshrine NHS funding in law as an item separate from the Budget. That Theresa May and then Boris Johnson have felt that this was necessary speaks more, frankly, about the lack of public trust in the Government to deliver what many people believe that the NHS needs to survive. It is their beloved NHS and they want it to survive.
As others have said, the elephant in the room in this Bill is the lack of any clarity about the funding of social care. Most experts and non-experts alike recognise that some of the most severe pressures on the NHS are because of the total crisis in social care funding, brought about by severe, sustained and repeated cuts in the revenue grants to local authorities.
The Bill provides an average increase of only 3.4% year -on-year in funding. As other noble Lords have mentioned, the King’s Fund and many others who have written to noble Lords have said that the NHS needs a minimum of 4% per annum to restore the NHS key performance measures and to start to take account of demographic change, which will impact more on the health service and social care than perhaps any other part of public spending.
It was interesting listening to the noble Baroness, Lady Penn, and I will gently chide her, as she has chided her own side, by reminding her about it being the largest cash settlement in the NHS’s history. Full Fact, an independent organisation, found that, while that is correct in cash terms, after inflation the rise is £20.5 billion, which was exceeded by a £24 billion real-terms increase between 2004-05 and 2009-10. Therefore, the comments from the Labour Benches today are absolutely on the money—it is about the money. If people believe that is more money but then discover that there is not, they will become very angry very quickly.
Therefore, the question for the Government is: will the increase in funding that they are putting into law bring about the changes that our NHS and social care system needs? I use that phrase repeatedly because the department decided to extend its name to the Department of Health and Social Care—despite the fact that the crisis in social care is because all the funding is in a different department and is not only not accessible but regarded in a completely different way.
A&E waiting times continue to increase. We have already heard that achievement of the four-hour standard target dropped to below 80% for the first time since the target was introduced. Is that what is behind the Government’s discussions about abandoning some of the health targets? We explored that in the debate introduced by the noble Lord, Lord Hunt, a couple of weeks ago. I remain concerned that losing some of those targets and identifying new things that are not targets but something else will change the focus of work. There is a place for performance targets in the public sector. They should not change things for the bad, and I believe that they have changed them for the good. If these and other targets are being missed, that demonstrates that there is a problem in the NHS, not a problem with the targets.
Workforce problems persist across the NHS, with one in 11 vacancies being unfilled. The noble Baroness, Lady Finlay, reminded us of the health implications of social inequalities, especially poverty. At Second Reading in another place, the Secretary of State talked about the priorities for the new funding: more GP appointments; new cancer screening and faster diagnosis; prevention, detection and treatment of cardiovascular disease; and investment in innovative technologies, such as genomics and artificial intelligence. Many noble Lords who have spoken today have touched on most of those points. However, if something is not a priority and the money provided for it is not sufficient, we have to worry. The priorities say nothing about mental health, social care or public health.
In recent days, we have heard from a number of organisations that have pointed to the problems with each of the privileged priority areas marked for special treatment, so even they think that what is being provided is not enough. We have heard from noble Lords that in order to deliver more GP appointments, we need more GPs. However, it takes time to train them and at the moment the problem is that they cannot be recruited. They are training as doctors then going elsewhere. It is almost like the discussions that we had four or five years ago about the reasons people could not be attracted into A&E work in hospitals. It was because it was perceived to be a difficult place to work, and primary care is now facing that too. We also need better clinical support services, including community nurses, especially on overnight shifts—a point that I will come back to in a moment—to support GP services.
Noble Lords have discussed the fundamental problem of recruitment and retention of doctors, including GPs, especially with the history of funding hospitals and secondary care over and above primary care. We all know that this will take a decade to resolve. However, it has been made significantly worse because EU and other national doctors are leaving primary care due to the hostile environment. They feel that they are no longer welcome to work in the United Kingdom. Salary bands alone will not make the UK an attractive place to work, so this Government will have to do considerably more to encourage recruitment from abroad. We will need that if we are to at least temporarily stop the problems that we have at the moment.
On cancer services, Cancer Research UK has pointed out that
“no allowances are made within this for the growing cost of staff required to run the NHS.”
How do we think cancer services are going to be run? It says:
“This is a significant oversight, and as pressure piles up on existing overworked NHS staff, patients are being let down.”
Much of what it says is echoed by those who work in cardiovascular services, and we should also be clear about what is needed to help social care survive. I thank the noble Lord, Lord Low, for his comments on that, and I am particularly grateful for the briefing from the MS Society. It reminds us that local authority funding has not kept pace with demographic pressures. For adult social care it is not just a not-inflation cost; it is cutting services off at the knees. Although the additional £1.5 billion promised at the recent spending round for 2021 is useful, experts believe that that is the minimum needed to keep the social care system going.
Looking ahead, there is a large funding gap to improve the system on a sustainable basis. Last year, as has been mentioned, the House of Lords Economic Affairs Committee estimated that improving care quality and addressing unmet need alone would require £8.1 billion in 2021. There is a big difference between £1.5 billion and just over £8 billion. The MS Society puts it in very human terms: one in three people living with multiple sclerosis is not getting the support they need to complete essential daily activities such as washing, dressing, eating or moving around the house safely.
It is worth remembering that the NHS Long Term Plan clearly states:
“Both the wellbeing of older people and pressures on the NHS are also linked to how well social care is functioning. When agreeing the NHS’ funding settlement the government therefore committed to ensure that adult social care funding is such that it does not impose any additional pressure on the NHS over the coming five years.”
Does the Minister believe that the amount allocated to adult social care is sufficient to avoid a negative impact on NHS constitutional standards? Does he believe that the amount allocated to adult social care is sufficient for local authorities to meet their duties as set out in the Care Act 2014? Given that we are told that the Treasury has asked all departments to prepare for 5% cuts, can the Minister confirm that the local authority grant for the next four years will have not only zero cuts but large and sustained growth for social care, public health and other parts of local authority budgets that impact on the health of the nation?
Investments in genomics and artificial intelligence—and other research, as we have heard from the noble Lord, Lord Willis—are important because we must constantly improve our health system and use technology and research to maintain much of our leading edge, not just in research but in treatment techniques.
It is disappointing not to see mental health services as a priority. How the Government can talk about parity of esteem without funding it seems somewhat astonishing. Sir Norman Lamb and the Liberal Democrats in coalition persuaded the Conservatives that we should talk about parity of esteem for mental health. Will the Minister tell us what that equates to in money terms? I will not repeat the arguments made by many noble Lords during this debate about the problems with CCGs cooking the books. There is no other phrase for it: they cook the books. If they can get a tick for delivering on mental health, and yet we know that the money is being diverted, that is a lacuna in the system and it needs to be plugged swiftly. What extra funding will the Government provide for mental health services and how will they insist that CCGs deliver it and are accountable, not just in some annual report but as the year progresses, to make sure that it is spent on mental health services?
I turn to another area that CCGs have been working on: services for children with serious medical conditions. CCGs have cut the support and care required for these children over the last two years to the point at which there are virtually no medical respite care centres left for children on ventilators who require PEGs for feeding. Actually, they have also cut community nursing services at weekends and overnight. It does not affect just children; they also serve people with cancer and other illnesses. If you have a feeding tube that comes out in the night, the only thing you can do is go to A&E. That is ridiculous. Sending someone to A&E, particularly if they are in a home, costs far more than having a regular night-service system of community health services; but CCGs can do it, so they do.
I have a long list—but I will not go through it because time will not let me—of the other services that need to be considered. I have made the point about children; others are musculoskeletal services, occupational therapy and physiotherapy. They are all struggling because they are not seen as a priority.
I began by talking about the lack of trust in the Government to fund the NHS at a level that would deliver real and sustained growth in services. On the Lib Dem Benches in both Houses, we will hold the Government to two comments made by Matt Hancock at Second Reading. First, he said:
“The legislation explicitly states that the Bill establishes a floor, not a ceiling, for how much we spend on … the day-to-day running costs of the NHS.”—[Official Report, Commons, 27/1/20; col. 564.]
Later he said:
“I can guarantee that the mental health funding will be ring-fenced.”—[Official Report, Commons 27/1/20; col. 568.]
We stand at a crossroads in NHS funding. The Bill starts to make provision for increased funding but is by no means enough to provide the growth needed to bring services back to previous levels; nor does it take account of demographic change. All of this is without any of the other pressures that noble Lords have described—what happens if we have a further coronavirus problem?—and obviously the Bill does not tackle the issues in social care, public health and other key services. If these are not funded urgently and properly, the Bill will be nothing more than a temporary sticking plaster on an arterial bleed. I look forward to the Minister’s response.
Baroness Thornton (Lab)
My Lords, I start by reporting to the House again that I am a lay member of my local CCG, as in the register of interests. I also put on record my thanks to the noble Baroness, Lady Blackwood, for her time as a Minister and for the briefing that she gave us before the break.
It is my job to wind up this debate from these Benches, and I appreciate that it is the job of the noble Lord, Lord Bethell, to do so as the Government’s spokesperson. However, I have to say that as far as we can tell there has never been a major health Bill Second Reading in your Lordships’ House that was not answered by a Health Minister. We all know how competent the noble Lord is—
Earl Attlee (Con)
Does the noble Baroness agree that my noble friend answers for Her Majesty’s Government and is a Minister of the Crown?
Baroness Thornton
I would just note that the noble Earl, who is an expert in procedure, was not actually in the debate that we have just had. We all know how competent the noble Lord, Lord Bethell, is at the Dispatch Box, but the Government put health at the centre of their programme. I think that it is not respectful to this House not to have a Health Minister in their place, and I look forward to there being one. If that is the noble Lord, Lord Bethell, that would be brilliant for him—I just want to put that on the record.
We have had some excellent contributions today. We are quite correct to use this opportunity to hold the Government to account, even if we cannot amend the Bill. As the noble Baroness, Lady Brinton, said, we have had many briefings asking us to pose questions during this debate, many of which have been reflected in the contributions that we have heard.
This is a short Bill, but I have to say that, even by the standards of some of the very daft legislation that we have seen from the Conservatives over the past few years, the NHS Funding Bill, all stages of which will be debated on your Lordships’ House today, is rather strange. We know that Boris Johnson, the Prime Minister, struggles to trust himself to carry out the things that he promised before and during the general election. In this case, it is the promise to increase NHS funding by £33 billion before the end of 2023-24—a promise that of course, as the noble Baroness, Lady Penn, said, was made in 2018 by his predecessor. To ensure that the Prime Minister meets his commitment, we have what my honourable friend Jonathan Ashworth has already said in the other place is a political gimmick: he has decided to put it on the statute book. Frankly, given Mr Johnson’s ongoing proximity to obeying the law and to the truth, that is probably no guarantee of anything at all.
In addition, with the proposed legislation designated as a money Bill, Peers will be unable to send any amendments back to the House of Commons for consideration. That is frustrating as the Bill, originally announced by Theresa May back in June 2018, contains, as many noble Lords have said, many serious problems and flaws. We agree with the King’s Fund, the Nuffield Trust and the Health Foundation that an increase of at least 4% is required to modernise and improve standards in the NHS, and that the 3.4% that this funding proposal brings might just about keep the show on the road. Indeed, as many other noble Lords have said, given that inflation is set to be higher than initially anticipated, the increase will be of even less value.
The Government’s proposals, as noble Lords have said, omit some very important factors. The Bill does not apply to the whole of the healthcare budget, and the exceptions mean it will not deliver, I believe, the transformation that the Government—and, indeed, all of us—desire. If the new funding is not accompanied by equivalent and sustainable investment in public health—we have had a discussion this afternoon that they do not even know what their budget is for the coming year in public health, which really makes their life impossible—social care and capital investment, the strains on the NHS will increase, storing up further problems for the future. Indeed, as many other noble Lords have said, the Bill does not address workforce, education and training.
Several noble Lords outlined the challenges that the NHS faces right now, so I will not repeat the issues about waiting times and trolley waits increasing, the 4.42 million people waiting for elective treatment and the delays of hospitalisation, often due to the lack of social care provision. Indeed, after this debate we will be discussing how we can deal with what might become a pandemic. We hope that it will not, but it adds to the serious challenges facing the NHS.
The British Medical Association is calling for a comprehensive spending plan that increases total health spending by at least 4.1% per year in real terms to address the gap between the funding of current services and future demand, and to put the NHS on a sustainable long-term footing. This equates to an extra £9.5 billion a year by 2023-24. What is the Minister’s view on that? I think the noble Lord, Lord Low, and the noble Baroness, Lady Brinton, together hit the nail on the head about social care, so I do not think I can add to that, except to echo that it has to be properly funded, otherwise this funding will not work. The strain on the NHS from the inadequacies of our social care system will ensure that it will not work. That, to me, seems to be a matter of the greatest urgency.
I am looking at capital investment. The NAO has reported that £4.3 billion was transferred from the capital budget to the revenue budget in the NHS between 2014-15 and 2018-19. The impact of these transfers can now be seen in an estimated backlog of maintenance of £6.5 billion. This affects patient care and safety: it means that there is water running down walls, so the wards cannot be used; it is a disruption of clinical services; and it means that the kit that people are using is outdated and, therefore, they have to be referred on because the X-rays and the MRI scans are not adequate. The Government’s stated aim of delivering the long-term plan will not be achievable without urgent and sustained investment in these areas through another multiyear settlement.
The Bill does not address staffing, as many other noble Lords have said. There are now over 106,000 vacancies across the NHS in England and no allowance seems to have been made for the growing cost of recruitment and retention of staff at every level, so the NHS people plan needs to be published urgently so that we can see how the Government intend to deliver on their commitment to support with the additional resources. As other noble Lords have said, Macmillan Cancer Support and Cancer Research UK say that adding 50,000 general nurses will not solve the crisis in the cancer workforce. Cancer Research UK says that the increase completely fails to address the significant and growing problem there is in the diagnostic workforce.
I turn to mental health. My noble friend Lord Bradley explained the urgent priorities there, particularly in children’s mental health services. As other noble Lords have said, mental illness represents up to 23% of the total burden of ill health in the UK but only 11% of the NHS budgets. So the Government will ensure the delivery of effective spending on mental health only if, as the noble Baroness, Lady Brinton, said, we have detailed breakdowns for each CCG, including separate figures for mental health investment and assessment, spending on learning disability and spending on dementia services.
In conclusion, I agree with my noble friend Lord Hunt about short-termism. Would the Minister care to look at the report from the noble Lord, Lord Patel, and its recommendations and proposals about short-termism and take them into account when discussing how to proceed with the long-term plan?
This week, we saw the launch of the Marmot 10-year review of health inequalities. As the noble Baroness, Lady Finlay, said, it makes very dismal and serious reading. It also shows the context in which our NHS is struggling to meet the appalling health inequalities facing the UK. As noble Lords have said, for the first decade in 100 years, life expectancy has failed to increase. As Sir Michael Marmot says:
“Put simply, if health has stopped improving it is a sign that society has stopped improving.”
The report points a finger at the all-too-familiar social and economic conditions that have increased health inequalities, which are now quite literally a matter of life and death. The NHS Funding Bill therefore should feed into a more general discussion about creating a fairer society and improving people’s well-being—and, by doing so, should help to improve the health of the whole population.
Lord Bethell
My Lords, I join those who have paid tribute to the work of my noble friend Lady Blackwood, my predecessor at the Dispatch Box, who made an invaluable contribution to the Department of Health and Social Care and is very sorely missed. I also thank the noble Baroness, Lady Thornton, for offering to join my campaign team. It is an offer that I am very happy to accept.
I was warned by the Chief Whip not to say that this was a vintage House of Lords debate and the House of Lords at its best, because it is hackneyed—but it is true. This has been a terrific debate, very highly informed and very challenging. There have been an enormous number of challenges in this debate—far too many for me to get through all of them—but I will try my best. Forgive me if I rattle through things a little.
I reassure the House that the NHS is the top priority of the British people, as a number of noble Lords have rightly pointed out, and of this Government. I know that there may be cynicism about the long-term plan that is being discussed today and about the Bill. The numbers that have been put forward in the Bill came from the NHS itself. The Bill enshrines those numbers in law. It is not a gimmick, and it is not Swiss cheese, as one noble Lord put it.
Lord Warner
I think most of us thought that these numbers came from NHS England, not the wider NHS. Can the Minister clarify that?
Lord Bethell
I am happy to accept that clarification. The noble Lord is exactly right: the numbers are from NHS England and they apply in that way.
To go back to Swiss cheese, the Bill is an ironclad guarantee to protect NHS funding. We are giving the NHS the certainty it needs to invest now for the long term. I thank the noble Lord, Lord Hunt, who put his finger on it. He spoke about the culture of short-termism and rightly mentioned—as did other noble Lords—the excellent report of the noble Lord, Lord Patel, on long-term sustainability. The natural human instinct to mitigate and to hedge when finances and money are uncertain has been remarked on in this debate. It is an entirely human instinct. The Government want to remove that uncertainty and to send a really clear signal to the system. We want to remove any sense of political risk about finance, so that decision-makers in the health system can make the best possible plans without looking over their shoulders to the finance director. They can instead be brave and make the best decisions possible and, in that way, implement the long-term plan in the most efficient way possible.
Where I have a difference of opinion with the noble Lord, Lord Hunt, is in his scepticism that reducing demand for hospital care is not possible. This Government believe that prevention is better than cure. That is why we are placing huge emphasis on community services, primary care and supporting people to live in the community, which reduces the number of people looking for acute care. We are investing in GPs and in urgent care centres to ensure that people are treated in the right place and at the right time.
I will talk first about the Bill in its essence. A number of Peers, including the noble Lord, Lord Hunt, have remarked that it is not enough money. I remind noble Lords that the plan comes from NHS England and that the Bill does not limit the amount of funding that we put into the NHS. Instead, it sets out a budget that must be at least what we have committed to. I reassure the noble Baroness, Lady Brinton, that this is not a cap. That is laid out clearly in Clause 1, which states:
“In making an allotment to the health service in England for each financial year specified in the table, the Secretary of State must allot an amount that is at least the amount specified in relation to that financial year.”
I will now tackle a few points of detail. The noble Baroness, Lady Thornton, asked about transfers from capital to revenue. We have said that such transfers were a short-term measure and are being phased out. Furthermore, the Treasury operates strict conditions on transferring between capital and revenue budgets. This is not a blanket ban. Sometimes technical adjustments between capital and revenue are needed for operational reasons, but these are a temporary measure.
The noble Lords, Lord Hunt and Lord Warner, asked about trust debt. We totally recognise that the stock of debt has grown and in recent years has become a significant financial challenge. We are working with NHS England and NHS Improvement to agree a framework of bringing provider debt down to an affordable level. We look to establish a new financing framework for 2020-21 that complements the NHS long-term plan.
The noble Baroness, Lady Finlay, was 100% right to raise the challenge of health inequality. We were all chastened by the Marmot review, which told uncomfortable truths. We completely accept the right to a long life. This Government are not ducking the challenge of health inequality. In fact, when we talk about levelling up, what could be a more vivid and valued form of levelling up than health equality? That is why we have put so much emphasis on laying down concrete commitments to these financial numbers and laying out, to the best of our ability, a long-term plan for the NHS.
The noble Lord, Lord Warner, asked a marathon six questions, which I will not be able to answer in their entirety. I will just tackle the question of cash not being index-linked and numbered. The NHS budget, like many other departmental settlements, is always set out in cash terms. This is essentially to deliver certainty. Experience has taught us that every time inflation goes up or down, budgets need to be reopened and confusion reigns. Furthermore, we as a House should remember that we are proposing a floor, not a ceiling; this is the kind of clear reassurance that has been asked for by the system.
I reassure the noble Baroness, Lady Brinton, that additional spending on the NHS in England absolutely leads to an increase in funding for the devolved Administrations through the Barnett formula—£7 billion for the Scottish Government from 2019-20 to 2023-24; £4 billion for the Welsh Government; and £2.3 billion for the Northern Ireland Executive. We will undertake a spending review later this year and will publish multiyear Barnett-based block grants for the devolved Administrations shortly afterwards.
Many noble Lords asked about the capital budget and quite reasonably asked why the Bill is about only revenue, not capital. The Bill is very much about protecting the record revenue spending for NHS England. However, we all know and totally acknowledge the requirement for capital investment. The Government have already made significant commitments: 40 new hospitals, with £2.7 billion for the first six; a further £2 billion capital spending, including £850 million for the first 20 hospital upgrades; and so on. I reassure the noble Lord, Lord Warner, and others, that further decisions about NHS capital will be made at a fiscal event in the very near future.
I note the comments of the noble Baroness, Lady Tyler, about the mental health estate and the use of wards. I reassure the House, and the noble Baroness in particular, that her arguments have been heard loud and clear. The Government recognise that the mental health estate is not satisfactory and are looking at ways to modernise these out-of-date buildings and arrangements.
The noble Lord, Lord Young, made a plea for GP surgeries. This resonates with me personally. The patient experience of arriving at a GP surgery is essential. Time and again, from my own experience, from what I know of human nature and from what I hear from patients, it is an unhappy one. In particular, the role of the receptionist at the GP surgery is unfortunate. I feel enormously for front-line professionals who have to deal with triage and the awkward conversations that take place. Something must be done to rethink the way we present ourselves to patients and that initial interface through the receptionist: a patient-first modernisation will be important.
Lord Bradley
Going back to the Minister’s comment about further capital announcements at an event in the very near future, will that allow the department to release the cash for the seventh hospital, North Manchester General?
Lord Bethell
The noble Lord asks a very good question. The answer is not in my mega briefing pack, but I will be very glad to get back to him if I find an answer.
The noble Lords, Lord Hunt and Lord Warner, asked, quite rightly, about maintenance, which is brought up during every hospital visit I make. We recognise the challenge that maintenance presents to the existing estate and the Government have recognised the need for further capital investment in the NHS by announcing, over the summer of 2019, a £1.8 billion increase in NHS capital spending, including £850 million for 20 more hospital upgrades. We know that more capital funding will be needed and this will be dealt with in the near future.
The noble Lord, Lord Bradley, asked about capital for North Manchester General Hospital and the prospects for a green light for the project. As part of our health infrastructure plan, 21 new-build projects across 34 hospitals are receiving £100 million seed funding to help plan their schemes and move on to the next stage. I am delighted that Manchester NHS will benefit from £4.6 million seed funding to help plan and redevelop North Manchester General Hospital.
I move from the Bill to the central thrust of the debate, which was not about the Bill itself, but about what was not in it. I start with mental health, because Peer after Peer addressed this subject. I reassure the House that spending on mental health in the NHS long-term plan is an absolutely massive priority for the Government. This historic level of investment—£2.3 billion by 2023-24—will ensure that this Government can drive forward one of the most ambitious mental health reform programmes anywhere in Europe. It will ensure that 380,000 more people per year will have access to psychological therapies; that 370,000 adults and older adults with severe mental illness can access better support; and that 345,000 children and young people will be able to access services.
I cannot say exactly how many of the nurses that we will recruit will be mental health nurses. That data is not available, but I can say that we are transforming community-based mental health support so that more people can be treated closer to home. We are ensuring that the NHS is delivering the commitment to increasing investment in mental health provision. As a result, we have required all clinical commissioning groups to meet the mental health investment standard. The noble Baroness, Lady Hollins, had some detailed and significant questions about how the mental health investment standard was being applied. Rather than try to give a half answer now, I suggest that we meet to discuss her data in detail. I should be glad to understand more about her concerns.
Baroness Hollins
I am grateful to the noble Lord for his response. He mentioned increased access to mental health services for many more people but, in my experience, people with learning disabilities and autism are often left out of those services and seen as requiring something different, whereas they need to be included in all services. Can he confirm and reassure me that that is the case in, for example, psychological therapies?
Lord Bethell
The noble Baroness makes an important point and her work in this area is well known. It would be, however, slightly outside the remit of the Bill to go into that in great detail. I do not have the answer she is looking for but should be glad to meet her to discuss this important matter. I share her concerns and my interests in the area are entirely aligned with hers.
My noble friend Lady Penn put us all on the rack regarding the mental health White Paper. I would very much like to give her the absolute date and concrete publication arrangements for it but that is slightly beyond me. However, I reassure her that it will be within the next few months; spring is the hoped-for arrival time.
Lord Bethell
My noble friend asks a question of such philosophical Whitehall subtlety that it is way beyond my pay grade to provide a clear, etymological answer to that. However, I reassure her that the matter is an enormous priority, and when I go back to the department I will lean on it hard to deliver this important publication.
The commentaries of my noble friend Lady Penn and the noble Baroness, Lady Tyler, on the visibility of spending on children’s mental health was important. The Government are 100% aligned on this. I noted the Minister of State from another place standing at the Bar, nodding with agreement while those words were being said. I know that a meeting has been agreed on this matter and a date is in the diary, I believe for next week, and I very much look forward to the outcome. I reassure the House that this question of visibility and publication is taken ex3tremely seriously.
The noble Baroness, Lady Tyler, asked about the mental health investment standard. CCGs are required to increase investment in mental health, as discussed earlier. All CCGs are on track to meet that standard, as the noble Baroness, Lady Hollins, rightly pointed out in 2019-20. I suggested in my previous speech that it would be premature to legislate for specific aspects in the Bill and capital will be considered in other fiscal events.
The noble Lord, Lord Bradley, spoke movingly about children’s mental health. I reassure the House that, in addition to increased mental health funding, we are implementing a progressive programme of transformational change for children and young people’s mental health services. This will include incentivising every school or college to identify and train a senior lead for mental health, creating new school and college-based mental health support teams, and piloting a four-week waiting time for children and young people’s specialised services.
The noble Lord, Lord Hunt, the noble Baroness, Lady Finlay, and others brought up the sensitive subject of adult social care. Fixing that long-term issue is one of the great challenges that this Government have taken to their shoulders. The reassurance I can give noble Lords is a political one. There are many complex questions to address, but our pledge as a Government has been clear: everybody will have safety and security, and nobody will be forced to sell their home to pay for care. Delivering on this promise will require an enormous amount of stakeholder engagement and political bridge-building, and we are embarking on that important process.
The noble Baroness, Lady Finlay, was quite right to say that social care workers are wrongly described as low skilled. I entirely agree with her sentiments; they are low paid but highly valued.
I am running out of time and have a few more points to make. I will jump to the conclusion and say that the Government take this Bill very seriously. The execution of the money involved in the Bill is also taken very seriously. There have been a number of exciting, important ideas about how that money should be spent from the noble Lords, Lord Willis and Lord Kakkar, among others.
We made our commitment in the manifesto and the Queen’s Speech to enshrine record NHS funding in law. We are delivering on that commitment and putting the NHS on a secure and stable footing for the future. The NHS belongs to us all, and this Government are backing that idea. I commend this Bill to the House.
Lord Warner
Before the Minister sits down, I have a question. I have been digesting his answer to me on inflation-proofing. Is he saying one way or the other whether these figures will be inflation-proofed annually, with the passage of time? Two-thirds of NHS costs are pay, and there will presumably be some pay increases. What is the Government’s position on inflation-proofing these figures?
Lord Bethell
It is the convention in the Treasury to express spending commitments in cash terms. That is the convention of government and how this Bill is expressed. It is not the commitment of government to uprate these figures necessarily according to inflation. They are adjusted for all the potential inflation that may happen. That said, if unexpected events happen or pressures are great, there is the opening and the capacity to increase spending if necessary.