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Baroness Merron (Lab)
My Lords, it may have been some weeks since this Statement was made in the other place, but its subject matter is as relevant today as it was when it first saw the light of day. The big questions remain: among them, where are the costings and how will it be funded?
The NHS is facing the worst crisis it has ever seen, with patients waiting longer than ever in A&E, stroke and heart attack victims waiting an hour for an ambulance and some 378,000 patients waiting more than a year for an operation. Those figures date back to the summer—before we even get to the winter and the challenges winter always brings.
At the time of the Statement, the NHS Confederation’s verdict was that
“these measures will not come close to ensuring patients who need to be seen can be within the timescales set out … they will have minimal impact on fixing the current problems that general practice is facing over the winter”.
But has not the situation got even worse since this Statement was first heard? The scale of the challenge faced by our health and social care services, the people who work in them and the public who rely on them has worsened as the state of the economy worsens. The country is now experiencing spiralling inflation which far exceeds the assumptions on which budgets were set, while those who work in the health and care services are struggling with the cost of living. What will be the response to this? How and where will the so-called efficiency savings demanded by the Treasury be found?
What we do know is that the impact will not be equal. As the right reverend Prelate the Bishop of London addressed at the weekend, it has been reported that the Government’s long-promised White Paper on health disparities has been dropped. Can the Minister confirm this? If that is not the case, can he advise on when can we expect this crucial plan to narrow the widening inequalities in health outcomes between the poorest and the wealthiest, between white and black, Asian and minority-ethnic people and between those in the north and south?
The Statement says that patients will be able to get a GP appointment within two weeks, but let us remind ourselves that, prior to 2010, the guarantee of an appointment was within two days, not merely an expectation of two weeks. Can the Minister provide more detail as to how the two-week expectation will be met? I ask this in the context of the record numbers of GPs indicating that they will be retiring or leaving the profession, where burnout and low morale are at an all-time high. How will the numbers stack up when 4,700 GPs have been cut over the past decade, and the long-promised 6,000 GPs are not on course to be delivered? With 330 practices having closed in just the last three years, where will these appointments take place? Are there plans to open new practices?
The gaping hole at the heart of the Statement is, as we know, the lack of a workforce strategy. In the ABCD plan presented by the Health Secretary, the only reference is under D, which refers to doctors and dentists. They are important—there is no doubt about that—but what about the nurses, paramedics, technicians, care workers, cleaners and caterers? Without a plan to tackle the whole staffing crisis, there is not a plan for the NHS.
What are the Government going to do about the staff shortages of 132,000 in the NHS today? This cannot be overlooked. Earlier today, the Minister told your Lordships’ House that there were 200,000 more staff in the NHS than 12 years ago. Perhaps he could elaborate further. Are these full-time equivalents? Where are they and what roles do they perform? Crucially, does the Minister accept that there still needs to be a fully costed plan to deliver the workforce that we so desperately need?
The Statement refers to some £500 million to speed up delayed discharges. Can the Minister help with some more detail on this? Is it a new investment or a re-announcement? How will it be funded? It is indeed right to say that if patients cannot get out through the back door of the hospital because care is not there in the community, we get more patients at the front door and more ambulances queuing at the front. That is exactly the situation we see today. The crucial point is that unless the Government act on care workers’ pay and conditions, employers will not be able to recruit and retain the staff they need. What is the plan to address this?
Finally, can the Minister reassure the House and patients across the country that the response to the crisis in the NHS will not be to lower standards for patients but to raise performance instead? I am sorry to say that this Statement misses the target. I hope the Minister will reflect on the points that I have raised, and other noble Lords will undoubtedly raise, and take the opportunity to use his new and important position to make proper change and improvement.
Baroness Brinton (LD)
My Lords, I echo the comments of the noble Baroness, Lady Merron, about the nature of the plan. It is full of warm words and aspiration, light on detail, especially on funding, and seems to disregard the reality on the ground at the moment. I also echo her concern about the rumours of the White Paper on inequalities being shelved. That is really important. Many of us spent a lot of time in your Lordships’ House during Covid hearing about the problems of people with Covid, particularly those from ethnic minorities and deprived backgrounds. There is a lot of data to say that those people have really struggled.
The workforce plan is something else that from these Benches we asked for consistently long before work started on the Health and Care Act, but absolutely consistently since then. Turning to the plan itself, on ambulances, the announcement in July was welcome but three months on—and this was an emergency announcement—it feels as if nothing has changed. The number of delayed discharges remains stubbornly high, and we know that there is a new wave of Covid rising: the ZOE study figures today suggest around 230,000 new daily cases and 2.2 million active cases. That is going to continue to rise: all the medical experts in this area say we are now definitely at the beginning of this wave.
B stands for backlogs, and I am afraid that that is not really improving either. Although it is good to see that the two-year waiting list is reducing, the under-two year list continues to grow: 6.8 million at the end of last month. The plan talks about patients being redirected from hospitals, but our primary care system—GPs, community nurses, physios, speech and language therapists in the community, and especially social care—is already at breaking point. It is good to be offering Covid boosters, but why are under-12s excluded unless they are immunocompromised? Children at schools without proper ventilation were drivers of the last two waves of Covid, and it just seems ridiculous that they have not been included, because that would be an easy win.
In my question earlier today, I asked the Minister about care and particularly about virtual hospitals. It is good that the plan is picking up on some excellence in the NHS, and I am very proud of my local hospital for doing it, but the Minister did not actually answer my question, which was: given that this work of virtual hospitals creates more work for GPs, community nurses, physiotherapists in the community that in the past would have been done in hospitals, will there be extra resources for primary care? Without it, primary care is already at breaking point; they cannot just magic extra time and energy to do it.
The section about GPs is admirable in spirit, but doctors have repeatedly said that their main problem is a lack of doctors. We also know from the BMA survey back in the spring that GPs’ workload has increased by 30% on clinical administration alone. It is not Covid; it is mainly to do with digitisation and complex systems. It is all very well talking about getting administrators in to do it, but these are administrative tasks that doctors have to do themselves. Unfortunately, it is causing a problem, and I do not see any solution in the plan.
Whenever Ministers talk about doctors, they talk about the highest number ever—indeed, the Minister did so earlier—but there are two problems with that. There are more patients than ever, and that is never reflected in any comments by Ministers. Government funding for doctor training has not been sustained. This year, far too many—hundreds, just under 1,000—newly qualified doctors, fresh out of university, could not get training places because there was no funding for hospitals to be able to do it. The exodus of NHS staff was reported in the Times just last Saturday. The net change is not positive now; it is negative.
On dentists, it is very good news about the simplification of government rules regarding overseas dentists qualifying to work, and we look forward to seeing the regulation shortly, but the main problem is the drastic need to overhaul the government contract. While the Statement says first steps are being taken, I ask the Minister when the major work funding for it will be concluded. Will he also tell your Lordships’ House what provision there will be for the 3 million people who are either immunosuppressed or immunocompromised—for example, because of blood cancer or because of strong medication which has to suppress their immune systems? The government advice on the web page still says that people in this group should not mix with people who are not fully vaccinated or may possibly be brewing Covid, but a year ago all support to this group was ended. Along with other people in this group, because I am one of them, I am about to have my sixth Covid jab, but I have no idea how long I am going to be protected for—that is why I wear a mask a lot of the time in the Chamber. Half a million of the most severely immunocompromised people cannot make any antibodies in response to the vaccine. They were promised antiviral medication or Evusheld. Five million doses of antivirals were ordered, but only 50,000 were handed out, and the Government have just refused to allow Evusheld to be used. What will the Minister do to ensure that this group of people will be protected?
Finally, the Health Service Journal has said that two out of three integrated care systems have fallen off track on their financial plans because of the impact of inflation, Covid cases not being funded this financial year and higher spending on agency staff. This plan will not work if the new integrated care systems cannot work. It is vital that the Minister tells us what plans there are to make sure that ICSs will be supported properly.
The plan for patients has many warm words for delivery. I know this is something the Minister cares greatly for, and we will support him, but the words on their own will not do it. Our NHS and care sector are on their knees already. The Nuffield Trust report says that data shows that even without the pandemic, the backlog would have been well over 5 million. It says the NHS was already stretched. I look forward to hearing the Minister explain how the NHS and care sector will be able to deliver on this plan in their current state.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Markham) (Con)
I thank noble Lords again for the warm welcome they have all given me today. I feel like an old hand already—I wish. Before I begin, I draw attention to my declaration of interests in the register as a new boy here, so to speak.
I am grateful to noble Lords for the interest they have shown in our plan for patients and will try to address the questions raised. As my right honourable friend the Secretary of State said in the other place, these measures across a number of important areas are the start, not the end, of our ambitions for health and care. They will help us to manage the pressures that health and care will face this winter and next, and they will improve these vital services for the long term.
First, I want to set down that there is record investment going into this area. In fact, we are spending about 12% of our GDP, which is the highest level ever. To answer the noble Baroness’s question directly, the 200,000 figure I gave was for FTEs since 2010. That means 200,000 more full-time equivalent employees in the health services than in 2010, so the investment is there, and we have a plan, set out in the plan for patients, to increase supply by 30% in terms of electives. I have seen some excellent examples of that already in Chase Farm Hospital, one of the new hospitals.
As I think I mentioned earlier, the new hospital build programme is one of the areas for which I am responsible; a £10 billion investment per year will go into capital programmes such as this and other initiatives. It is all about increasing supply by 30%, because we will be able to get on top of these issues only if we increase supply.
At the same time, as has been drawn out, I appreciate that we face an unprecedented challenge in the levels of Covid we are seeing and in flu respiratory issues; we have had less warning about that than ever before, because normally we can see what happens in Australia and use that as a warning. I am aware that we are likely to face more challenges there than ever. At the same time, we are putting forward the beginnings of a long-term plan to tackle this. I will talk about that and, I hope, answer the questions raised—my own ABCD, if I may.
I will start with care, because not only is it important in its own right to make sure that people are cared for in the correct place—it is much better and more cost effective for people to be in a care home than in a hospital—but freeing that up will free up the whole system. We all know the problem is often that A&E is full because it cannot put patients into hospital beds and therefore the ambulances cannot release their patients into A&E, backing up all the way through the system. That is why one of my priorities is the care side.
I will need to get back to the noble Baroness, Lady Brinton, on virtual wards in terms of support for GPs. I have seen the excellence at first hand, and the incredible reduction in figures that it can make, so to my mind we should focus on that and make sure that GPs and their surgeries have the right focus and support to help them. I will follow up with the noble Baroness with more detail on that, if I may.
I see this as key to care and the £500 million spend—again, I will give the noble Baroness, Lady Merron, details of how that is being used, because we want to make sure that we work with the integrated care boards, as she said, to ensure that it works to best effect. With that, I think we will start to see improvements come in for A&E and ambulances. As I mentioned before, we have seen a 10% increase in staff there versus 2019-20; that is what the 7,000 new beds are all about.
However, in terms of performance, we have seen great disparities. I am sure noble Lords have heard before the statistic that 15 of the hospital trusts account for 45% of all waits. I want to understand why that is. It is fair enough to trot out that statistic—I expect noble Lords to challenge me in a couple of months’ time to ask what was happening in those 15 trusts and what I have done to put it right and make sure they are performing well. My task is very much to put them under the spotlight and try to understand how we can perform much better in some areas and take those learnings to help them in others. I am under no illusions that it is tough out there. My wife is a dentist, so I have some knowledge of this; also, my mother was a practice nurse, so I understand how important and tough the role is.
Working through the backlogs and getting on top of the waiting lists will be key. There is an £8 billion programme, as we are all aware, to increase supply by 30%. I have seen fantastic examples at Chase Farm, as I have mentioned, and Watford of robotic surgery—I had the pleasure of playing with it myself, though not on a real patient—that I am sure will be revolutionary and transformative. It is about doctors, dentists and all care workers—all of them. As I say, I have a particular interest in the nursing profession.
It is all about releasing the 50 million more appointments, which I am glad to say we are making progress on. A lot of that is about making sure that you see the person best suited to meet your needs. We must make sure that we use GPs where they will best meet those needs. They are our most skilled specialist resource, so I want to make sure that they are focused on the cases that are best for them. As I say, I have experience through my mother’s role as a practice nurse of how much she could do and how much we can use them to meet a lot of the appointments targets—and make it a better job for them, because they have the skills and can be very valuable. The same is true of community pharmacies. Funnily enough, I worked at one in my first job—many years ago—so I have a little experience of that. It is all about trying to expand capacity.
I apologise, I cannot answer the noble Baroness, Lady Brinton, right now on the 3 million immunosuppressed so I will need to get back to her on that.
As the noble Baroness, Lady Merron, said, it is about trying to raise performance across all areas. The brilliant thing is that we have seen very good areas—I am sure we have all seen them when we visit hospitals—which have excellent performance, but my feeling, coming in as a bit of an outsider from business, is that it is patchy. There is an opportunity to spread that performance, really understand what good looks like and do more work to make sure that it is spread across the system. Part of my remit will very much be the performance agenda and working with the NHS executive team to make sure we see those improvements across the board.
I hope that gives noble Lords a flavour of how I hope to address what we see as our plan for patients. It is our commitment to what our patients can expect. I hope we can see that it is proactive, not prescriptive; ambitious but also achievable. We hope that, by empowering patients, they can start to challenge and drive performance as part of that, as a first step. Through that, we will be able to help, as part of the long-term plan, both the NHS and health and social care deliver for them. As such, I commend this Statement to your Lordships’ House.
Baroness Watkins of Tavistock (CB)
My Lords, I welcome the new Minister and declare my interests, in particular that I share his interest in the nursing profession. I have two questions. One is about the 15 units where particular problems have been identified. Does he think that is to do with demography, particularly older populations, and that we have got the funding calculation right in those areas? Secondly, is he prepared to meet me to talk about retaining people who are currently qualifying who, if they do overtime, are being hit with the 9% repayment for their student loans? This means there is very little incentive for the younger generation to do overtime, despite their being the fittest and probably most able to do so.
Lord Markham (Con)
On the 15 trust areas, I will need to get back to the noble Baroness on whether it is down to demographic factors. I wish to dig into it more and will look at a number of things. I have been told anecdotally that the day of the week makes a big difference to performance and wait time, so that is another area I want to get underneath. In terms of retaining people, as an entrepreneur who has started up many businesses, I know the importance of motivating a workforce. Clearly, if work does not pay—for want of a better word—there is not much motivation to put in the extra hours we require. I will come back to the noble Baroness with more information on that.
Baroness Tyler of Enfield (LD)
My Lords, I welcome the Minister to his new role and declare an interest as a non-executive director of the Royal Free London group of hospitals, which includes Chase Farm. I would like to pursue the points made by both the noble Baroness, Lady Merron, and my noble friend Lady Brinton about health inequalities. With an almost 20-year gap in healthy life expectancy between the most and least deprived areas in London, could the Minister say if and when the Government are planning to publish the health disparities White Paper?
Lord Markham (Con)
I thank the noble Baroness for reminding me that I failed to reply to that point earlier and for giving me the opportunity to do so, but I will need to investigate further. As I say, I do not have immediate knowledge of this issue, but I undertake to come back to the noble Baroness with a reply.
Viscount Stansgate (Lab)
My Lords, I welcome the Minister to the Dispatch Box. I am sorry I missed his first outing earlier today; in fact, I had a medical appointment. Whatever the definition of “challenge”, it must include the position of a Minister representing the Department of Health on the Front Bench of this House—so good luck. The Statement makes the bold claim that up to a million GP appointments can be freed by
“changing funding rules to give freedoms to GPs to boost the number of staff to support their practice.”—[Official Report, Commons, 22/9/22; col. 832.]
Can the Minister explain exactly what that means?
Lord Markham (Con)
I thank the noble Viscount for his good luck wishes. I do not understand completely the economics of the doctor’s surgery yet. I want to get my head around that, because I understand that a surgery needs to be set up so that it can be a successful business for them and can have the proper infrastructure. I am very interested in the dentistry field as well; as I said, I have an interest in terms of my wife. But I realise that in a lot of these situations, you are asking doctors and dentists, who are trained to be excellent medics, to effectively set up their own business. That is a quite different thing and demands quite different skill sets. I believe that we need to have a package of support to help them in this respect. As part of that, we need to understand exactly what funding can be used and whether it gives them the headroom—for want of a better word—to allow them to do those elements and have the support staff in the numbers they need. Understanding further this area is on my to-do list, and I would like to get back to the noble Viscount as soon as I can.
Baroness Finlay of Llandaff (CB)
I also welcome the Minister to his post, which I think is probably one of the trickiest ministerial posts in government. I declare that I am a registered medical practitioner and remain on the clinical register. I would like to briefly return to the question of workforce. We have spoken about doctors, dentists and nurses; in addition, there are allied health professionals. I should state here that I am president of the Chartered Society of Physiotherapy.
I have come across a lot of professionals who have had time working abroad, for one reason or another, and who have remained clinically up to date but find it extremely difficult to get back on to the register. I have also had conversations with retired professionals who have been allowed to be reregistered under the Covid regulations but find that, because they do not have a responsible officer, it is extremely expensive for them to undertake the processes to come back on the register.
In addition, I have also had conversations with refugees. We have a lot of refugee doctors, dentists, nurses and allied health professionals who currently are completely unable to work because they have not gone through the different exam processes—yet all the time they are not working, they are losing some of their clinical skills. Will the Minister meet with me, because I think there are some ways, in conjunction with the registration bodies, that we could possibly create a provisional registration category to allow these people’s skills to be used rapidly for the good of the NHS, rather than waiting the several years it would take them to get through the different hurdles laid before them?
As part of that, these clinicians—particularly doctors and nurses—could then have input into 111, where we know that currently only 40% of calls have a clinical input. The Royal College of Emergency Medicine has calculated that this figure needs to be 65% of all calls in order to decrease the demand on A&E departments from calls to 111. Will the Minister meet with me fairly urgently? It seems a waste to have people who want to get back on the register but, for many reasons, cannot.
Lord Markham (Con)
I thank the noble Baroness, Lady Finlay, for those excellent points. I have to declare a further interest: my wife is not only a dentist, she is a dentist originally from the Dominican Republic who practised in Spain for 20 years before coming here. So many of the excellent points the noble Baroness made are well recognised here. I am in the market for good ideas, so I will meet with the noble Baroness with pleasure to understand and discuss some of the ideas she spoke about.
Baroness Walmsley (LD)
My Lords, the health service is suffering from inflation in the same way as the rest of us. Julian Kelly, NHS England’s chief finance officer, told the board recently that it will have to find £20 billion in efficiency savings over the next three years because of the increased cost of goods and services that it buys. He said that
“clearly you have to completely revisit investment in cancer and mental health, primary care … diagnostic capacity and you would have to look at what it meant in total for what the NHS could deliver.”
With that situation, could the Minister say how on earth we are going to deliver the plan for patients?
Lord Markham (Con)
As I mentioned earlier, yes, there are inflationary pressures, but as a percentage of our national wealth—our GDP—we are investing more than ever before, at around 12%. That level is very high compared with most other OECD countries. So, the investment and the staffing are there. I think the correct challenge, which I have heard from a number of Members today, is whether we are getting the best performance out of that money and investment. Again, that is very much where I have been brought in—to make sure that we are taking those areas that are performing well and disseminating that good practice. That is where I would like to focus my attention, to make sure that we really are getting the maximum output possible from this record level of investment.
Lord Walney (CB)
I add my welcome to the Minister, and I ask him about the issue of unmet need in the care sector from local authorities. His predecessor gave a Written Answer to my noble friend Lord Stevens earlier this year which made it clear that the Government do not currently record the scale of the unmet need from care packages that cannot be offered by local authorities. The Minister brings a considerable amount of expertise to this; does he recognise that that is a shortcoming, an issue, and is it something he would like to see his department address?
Lord Markham (Con)
I thank the noble Lord, Lord Walney. Another part of my many and varied background is as a previous deputy leader of Westminster Council, so I realise the importance of local authorities in this role. I will not confess to being familiar with that scale of unmet need at the moment, but I thank the noble Lord for raising that issue. I will make sure I go and find out more on it and, if I may, come back with a written response.
Lord Scriven (LD)
My Lords, I also welcome the Minister to his role and wish him well, because of the crisis that the NHS and social care face. In asking my question, I also declare my interest as a non-executive director of Chesterfield Royal Hospital’s NHS trust and as a vice-president of the Local Government Association. The Conservative cabinet member for adult social care in Devon said in the last couple of weeks:
“We are … in crisis mode … It is very difficult because you can stack shelves in supermarkets and earn more money than you can in social care. We need to see national government”
respond to this urgently. If all the £500 million given to social care—assuming that this money, because it is short term, is to last for six months—was to be equally distributed between the salaries of the 1.5 million people in social care, it equates to just 31p per hour more, which would still be below the market rate for some supermarket shelf stackers. So what is going to happen to make sure that enough resources go towards dealing with the crisis in social care, so that need can be met and staff can be retained?
Lord Markham (Con)
We live in a time of a very competitive jobs market and such a competitive market brings challenges with it, as the noble Lord says. We need to make sure that people feel that these jobs not only are recognised as important but make sense economically for them as well. We are investing £15 million in expanding our recruitment and resourcing to attract more people into the industry. We also need to look overseas and I think many are aware of our plans to do that. It is not lost on the team over here that we need to make sure that this is an attractive job and career for people to move into.
Baroness Bennett of Manor Castle (GP)
My Lords, I join others in welcoming the Minister to his new place. I acknowledge that he has stepped in very late in the piece to pick up this Statement, but we are right to ask questions on it. Unlike the noble Baronesses on the Front Benches, I want to address the issue of the number and supply of doctors, particularly GPs. There are some strong statements here about “setting the expectation” of getting an appointment within two weeks, “opening up time” for 1 million more appointments and helping practices “improve performance”. Think about what GP practices have done in improving performance: there were 4.9 million more appointments in December 2021 than there had been two years previously—a 20% rise. A BMA survey found that nine out of 10 doctors reported that their workload was excessive and dangerous. This Statement says that there will be more and more GP appointments, but where will the doctors needed to provide this service in a healthy and safe manner come from?
Lord Markham (Con)
As I mentioned, we have 3,500 more doctors, but the 50 million more appointments target, which we are well on the way to delivering, is from not just GPs but across the piece. It is also from nurses and community pharmacies. I think we would all agree that doctors are our most precious resource. Given the comments on not wishing to overburden them and the stresses of that, we need to make sure that their limited time is focused on the patients that most essentially need that time. We are expanding supply and spreading it among nurses—as I mentioned, from my experience with my mother, they are very capable and willing to pick up a lot—and among pharmacies as well.
Baroness Merron (Lab)
My Lords, I appreciate the answers that the Minister has given your Lordships’ House, but would he be good enough to write to address a number of the more detailed questions raised and give the information requested?
Lord Markham (Con)
I thank the noble Baroness for giving me that opportunity. I wish to be part of this House as someone who is open and collaborative, so I will take the opportunity and fulfil it to the best of my ability, to make sure I can give complete and thorough answers. I will also aim to make myself available, because these things are often best carried out through a conversation. I have tried to answer as well as I can today, but I will gladly follow up with more detail.