(1 year ago)
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Lord Scriven
That this House takes note of the current performance of the NHS and innovation in the health service.
Lord Scriven (LD)
My Lords, I clearly need to put a different aftershave on tomorrow.
I wanted to have this debate because I feel that the time is right for a discussion to be had in this Parliament that really focuses on the future of the NHS and that asks some fundamental questions that will hopefully stimulate further discussion in senior positions in government, NHS England, the professions in the service and the population. Today I want us to have a discussion based on mature politics, rather than the normal knock-around. I think the Minister will be quite surprised that I, of all people, am saying that. It is fascinating that most of the debate on the NHS and health—when they are discussed in this building, in both Chambers—is predominantly about how to tinker with or improve the existing system. It is very rare that we step back and ask some fundamental questions about the system itself and the outcomes that it achieves.
I could go in depth into the performance of the NHS and the processes and measures that are in place that dictate the behaviour about how people in the NHS then perform and what is seen as important. It could be about the 7 million people waiting for care. It could be about the lack of fast access to some cancer services or the length of time it takes to get an appointment with a GP. It could be about the length of time it takes an ambulance to arrive if you ring 999. It could be about the inability to get good oral health through having access to an NHS dentist. It might be about the real lack of parity of health services between mental health and physical health. I could point out the rate at which community pharmacies are closing and the effect that that has within communities. Again, I could point out the poor access to, and rising wave of problems in, sexual health services. Of course, one cannot discuss the performance of the health service without saying that the crisis in social care has a direct effect on the health of the population.
If I do that, however, the Minister will come back with a ream of figures about what the Government are doing to improve the present system. The Minister will come back with a platitude of figures about what is happening. That is all about the process, but we need to start from the outcomes of what the health service is trying to do. What we are trying to do is to fix the infrastructure of a health service devised in the 1940s for a 21st-century Britain.
Let me give the House an example of how this could change. I work with a country in Africa where people said, “We do not have enough pharmacists”. This is a rural country with three urban centres and a massive rural area the size of Italy. “We do not have enough pharmacists; we need more pharmacists,” they said. However, when you start asking what the purpose is of pharmacy and pharmacists, and what their role is in the healthcare system to improve the outcomes of patients, part of the answer is that it is about the distribution of the correct drugs at the correct time to the correct people, so that they can lead as independent a life as possible. They got to the point of thinking about posing the question slightly differently. The answer was not about more pharmacies; what they did was to innovate, based on a different question. They got drones with compartments for drugs going to a central depository and then flying, docking on solar-panel charges; the compartment for that village opened; somebody in that village had been given a job to distribute to that village; and then the drone went to the next village. It was not extra pharmacists that were required; it was access to drugs that was required. By asking a different question and starting with the outcome, you stop just going absolutely focused on process.
I am sure that, at some point in this debate, the Minister will tell us that new hospitals are being built. I am not going to go into numbers of hospitals, but we never question what a 21st-century hospital is. What are we actually building? Are we building the existing model, which in some way replicates the problem of people not being able to get access to planned elective care, because emergency care pushes it out? I know lots of medical people—doctors, nurses and others—and they all say that the reason why I cannot get my hip replacement or I cannot get my ophthalmic eye problem seen to is that emergency care takes over the theatres. One of the things we have to do, therefore, is to say that hospitals need to be different.
It is the same with primary care. We have to think about what primary care will be needed for the future. I will come on to some of the ideas that I have, but innovation is not just about technology and data. It starts with culture, leadership and thinking. It is really important. The Government will tell us—when I go into some of the things that I am suggesting—“Oh, we already have that with ICBs and ICSs”. No, we do not; what we have is a governance structure. ICBs and ICSs become obsessed with structure and governance, and they are not given the space to innovate.
A key, central issue with the NHS that we need to address as a nation is that in some areas, we might just be doing the wrong things a little bit better. It was telling that, in all the great briefings that we had for this debate—many organisations gave us excellent ones— most of them focused on the acute sector and what was needed to improve it. That is quite clearly a vision of health shared by many people who work in the health service. Therefore, if we start with a different view on performance and the purpose of the NHS, we will start with a very different discussion about what is required to innovate, to improve outcomes and not just to tinker with the present system.
If we start to look at the purpose of the NHS as to reduce health inequalities, it might lead to a different discussion—a different focus on innovation to improve outcomes and reduce health inequalities, not just to keep the system running a bit better than it is. If we say that the purpose of the health service is to help in partnership to increase the number of healthy years lived and to ensure that people retain their independence and dignity, the focus on behaviour, structures and systems will be different. That will lead to the NHS having to think much more about population and community health approaches. It will lead to a step change in what is seen as vital to improve health, so it is not just about drugs, doctors and operations in the present but about a shift in who does what, where and how. I do not suggest that hospitals and operations are not important—of course they are—but they are only part of the jigsaw, and too many people see them as the only part of it.
I will suggest some changes. I am not suggesting that these changes need to be adopted but that we just need to think about a different approach. Some of the innovations that might be required might be the following. Do we have different types of hospital: acute hospitals and non-acute hospitals, tertiary hospitals and planned elective hospitals? There are pros and cons for the existing and alternative models, but the issue is what we actually do so that for those who have a planned operation, the whole system works and innovates to meet their needs and they are not stopped going to their emergency care.
Where are step-down services? What innovation do we have around those, so that when people are in the recuperation phase, services are provided? Should the primary care model exist in its present form? Should we have a different type of approach to primary care, so that people like me, who probably go to my GP once every six, seven or eight years, have a different model from those who have ongoing care needs with comorbidities?
I will go further. Do I have to register with a GP at all? If we are going to unleash the potential of pharmacists, who say that now, with the correct funding and system, they could do away with 30 million GP appointments a year, should I register with a pharmacist? A pharmacist can build services around them, linked to IT, to data, and to my healthcare record. I do not suggest that that would work—there would be problems—but we have to ask some fundamental questions.
What is the role of the people who provide care and health provision for people allied to medicine—the OTs and physiotherapists? Predominantly, it is still an acute service. There are people in the community sector. There has to be a huge shift. If we are looking at outcomes, keeping people in hospital to have their OT or physiotherapy is ridiculous. We have to think about how we do this. With older people, for example, one of the biggest issues when you look holistically is social isolation. Yet the health service, for reasons to do with efficiency, has moved that provision back into somebody’s house rather than thinking more holistically about independence and dignity and what can be done in the community with other partners to provide not just the physical part of healthcare but the well-being in terms of stopping social isolation.
Central to all this is people’s lived experiences and that being central to part of healthcare planning and provision. That is something big. Innovation is not just about the data or the technical stuff but about the people. It is about leadership, both clinical and non-clinical, and the type of training that is required. In the future it will not just be about technical specialists but about a community-based approach which will mean that people will have to be great facilitators and bringers-together of networks to be able to build services around shared outcomes based on real people’s lived experiences. That has a big impact for the forthcoming workforce plan. It has to be a workforce plan for the future, not just on how we are going to fit the gaps that already exist in the service, otherwise we will be on a merry-go-round—so I will be quite interested to know the Government’s thinking on this.
In finishing, I say that this debate has to be about the future. It has to be about data, IT and artificial intelligence, but it also has to be about the culture and leadership, and about a community approach which completely changes just tinkering with the existing system, thinking instead about what is required and what innovation is needed for a future health service provision. I beg to move.
Lord Parekh (Lab)
My Lords, I thank the noble Lord, Lord Scriven, for introducing this debate.
The NHS turns 75 in July this year. Right from the time it was born, it has been based on a simple principle: it is funded by tax and free at the point of delivery. Over the years, it has become an integral part of the British way of life and has even come to be called a national religion. I share this degree of confidence in the system. However, at the same time, as anyone who has turned 75—as I have—can say, things do begin to go wrong and memory begins to play tricks. I want to use this opportunity to look at the NHS over the last 75 years and say something about the way in which institutionalised memories have begun to fail, how things have begun to go wrong, and why, unless we do something drastic, we might end up regretting its demise. I will itemise five or six major criticisms of the NHS so that the Minister can reply to each of them separately.
The first striking thing about the NHS is that it is hospital centred. Half of all the GP appointments and 70% of the in-patient bed days are taken up by those with long-term conditions such as diabetes and others. Those people are best treated by GPs and nurses, yet only 8% of the NHS budget goes to general practice and community care. If one looks at the allocation of resources, far more resources go to hospitals than to GPs or community care, and one fails to see the point of that.
The second criticism I have of the NHS is that it is not only hospital centred but sickness centred. It is not the National Health Service but the national sickness service. It is supposed to cater to sick people. We are, for example, the third-fattest country in Europe, and an obese person costs twice as much to treat as one who is not obese, yet very little is done to encourage the positive health of the people of this country. We should be concentrating on encouraging people to maintain good health and to exercise and eat well—all sorts of things—not just treating illnesses that result from the failure to do this.
My third point is on the use of medical technology. It is very striking, for example, that ours must be one of very few countries where X-ray machines and CT scans have, at least until recently, not been used on a Sunday, or even Saturday, or public holidays. When I was in the States, it was quite common to get an appointment on a Saturday or Sunday, when those machines were in use.
My other point is about the distribution of money. I have already talked about the distribution of money between GPs—primary care as opposed to hospitals—but there is also the way it is done among the medical profession itself. I have been critical of the merit promotion system, and I have asked Ministers to explain to me the logic of it. In no other profession do you get the merit promotion system. If I get a Nobel prize in literature tomorrow, my salary will not automatically go up, nor will I get an extra increment. Why should doctors be able to get merit-based promotions: merit based on what? Merit is simply a part of what they are supposed to achieve anyway. I am told that merit promotion is not a question of just a few hundred pounds: the budget comes to quite a lot. The question is whether that money could not be used for other purposes.
There is also the danger, as is quite often pointed out, of overmedicalisation. There is sometimes what is called disease-mongering, a phrase that was first used in 1992. Imagine that a disease is invented because certain symptoms are not easily explained. The pharmaceutical industry has a vested interest in inventing diseases and getting people worried about them. Repeat prescriptions keep up the supply of medicines even when they are not used, and there is what is called defensive medicine, whereby doctors keep doing something because they are supposed to be doing something rather than doing nothing. Professor David Haslam has pointed out many of these things in his new book, Side Effects.
I have a couple of other points. I have often wondered about the poor co-ordination between GPs and specialists in hospital. There is a hierarchy between them which I had not noticed, and a hierarchy that means that hospital specialists carry a greater degree of authority than the GP. I have faced cases which puzzled me, when a hospital specialist would recommend a particular medicine, my GP would follow his advice and I would say, “Look, doctor, I don’t think this is right, because this has been given to me once in the past and it had an adverse effect”, but the doctor would say, “I can’t disregard what the specialist has said: he is my superior”. The result was that I had to pay the price for taking a drug which I should not have taken. There are cases where the hospital specialist’s authority is supposed to be unchallenged.
I have often wondered why, in order to go to a hospital specialist, I need to go through the GP route—why I cannot go directly. When the hospital specialist sends in a report, it comes to me via my GP. It takes days to arrive, when a copy could be sent to me directly. Again, from experience, there have been recent cases when I saw a specialist and I should have had the report, but I am still waiting for it because it will take days and days to travel to me.
My last, important point is that there is too much distance between hospital and the local community. The hospital is generally not in direct, regular contact with the local community. It is a separate place where you are sent by your doctor, or you go yourself to accident and emergency. There is no regular interaction between hospital staff and ordinary members of the community, there are no common social events which bring them together, there is no sense of identification by the local community with the hospital, and the result is quite obvious. I have asked for some statistics. It is very striking, when people make their will, how much of their money is directed to the local hospital. The answer is: very little. Why is it that hospitals do not come into the category of those to whom you would leave your legacy? You could leave your legacy to the school or the university, but rarely to the hospital because, unlike schools and universities, hospitals are not seen as an integral part of the community. There must be some way in which hospitals can become an integral part, taking an active interest in promoting the culture of good health within the community.
Broadly, my suggestions are meant simply to accelerate the regeneration of the NHS, because I do not think we can wait too long before the current situation creates a crisis.
Lord Addington (LD)
My Lords, this is one of those debates where we all think we know what is going to be said, but hopefully we are all mildly surprised. My noble friend started this process by hitting the nail straight on the head, saying—I paraphrase, but I formed this impression—that we are dealing with everybody after they have fallen over, not making sure there is not something to slip on. We have a system which seems to be in almost terminal crisis, according to many politicians—it is always the politicians who are not in power—and we are always sitting in here trying to rescue it.
I have a bit of a track record on this issue. I think the first debate I spoke in when the Minister who will reply today was here was about trying to change the nature of what we do with health, and to improve the surrounding structure. It was on a Private Member’s Bill that was a wonderful thing, but the Government have decided otherwise. Health promotion has far greater potential than does the pharmaceutical industry for making sure we have a healthier society. Clean water and clean air have saved more lives than all the drugs piled up together. You put that together with a decent diet, and people survive.
But we have the health service in a box. How do we make sure that the health service influences the rest of society? We do not do it from behind a Chinese wall in Westminster, the punching through of which requires a huge act of will, either way. You can tell the Ministers who take that on: they have metaphorically bandaged hands from doing it. They are always trying to get through, and everybody thinks it is down something else. The priority is always the emergencies and no one has the authority to say, “No, we have got to carry on with this and other departments must change their activity and talk to us”. This strikes me all the time: those little battles you have constantly.
For instance, let us take one of my favourite subjects, sport. Good sporting activity means you are generally healthier and in contact with the rest of humanity, which is good for your mental health. In fact, the mental health benefits of sport and social interaction may outweigh the physical ones. We know that if you have good mental health, you are more likely to undertake physical activity. It is a virtuous circle. What is required? It might be making sure that we have a tax regime and a minor support structure that allows our voluntary-inspired amateur sports teams to continue more easily, being as generous and helpful as we can and not leaving them constantly struggling for finance.
We are very lucky in this country: we went first for amateur sport and did it by people doing it for themselves, outside the state system. The state does not have to do it. In France, you play your rugby, football or tennis at the stades municipaux.
In Germany—this is an example I have used before—I remember that, whereas the FA said, “We spend X number of million pounds on improving the number of pitches we have”, the Bundesliga turned round and said, “What are you talking about? That’s a local government job”. We need support for those structures; the Government must have some way of saying, “This is something for more than just local government or the Department for Education. It is more than just money taken from the lottery. It is something that the health service and the public health environment have an active interest in”.
Some of this will be purely bureaucratic, such as making sure that these structures are always available; part of it might concern planning. How many amateur sports teams have done the wonderful thing of killing off their junior sides by getting a deal on their ground and moving out of town to somewhere where there is no bus service? That is a great way to destroy a junior team. I bet that most people do not even take that into account when they do it. I bet that most sporting bodies are not advised when these people move; they all work in structures. Do not do it: you are going to damage your junior structure. There will always be a developer waving a chequebook at you, but you have to make sure that you can actually get there.
That is just for the amateur sports structures; we can then go on to say, “We have done things like, under the Agriculture Act”, as I remember being told, “farmers will get support to create footpaths”. Great—but who is telling those farmers to link in with existing footpaths and public service networks, or at least to have good car parking, so that there is a structure where everything can be used together? I have not seen that. I have not heard of somebody doing that, for instance by telling the Ramblers’ Association or others, “Please talk to each other and create better networks”—so that, for instance, if you are going for a walk or going somewhere else, you can either get public transport or get back to where you parked your car. That might allow the local community to have a better chance of sustaining a café, a shop or a pub. All these things come together; we have to think slightly more holistically on this. When it comes to encouraging people to walk casually to and from work, we all know the answer: make sure that the streets are comparatively clean and well lit. All these things come back into creating a healthier society.
We can even go further than that; I was going to save this point for a little while longer, but my party has been, quite rightly, raising awareness of water quality and sewage discharges. If you want people to do things such as wild swimming and boating, making sure that they do not come face to face with a turd is a good idea, to be perfectly honest. Can we make sure that the weight of public opinion on public health—indeed, the public’s reverence for the health service—is used to influence the rest of this structure? If we do, we will have something that can get in there. We will not do this by standing behind Chinese walls. We need something that will go beyond and talk. If we do this, we stand a chance of making these improvements that mean that the acute services are called on later and less frequently. The huge bureaucracy, which may or may not be dealt with at some point in the future, will at least be called into action less often. However, this will require somebody to go in there and annoy people and say, “Please talk to each other”.
I have been in Parliament more than long enough to know that, if you want to make a speech on anything, talking about getting two government departments to work together and how they do not do it is probably good for five minutes; let us face it, it always has been. However, in this instance, we already have cases of it. We have the first steps. I hope that, in future, a Government will be brave enough to take this issue on—that is, to turn round and say, “We need better sports education and a structure to get people involved”. That may well lead to something like a good social hub, which, if they are at all sensible, will be able to be accessed by people from outside the sporting community. We have to maintain buildings where any activity can take place.
If that is going on and people are interacting with each other across the whole of government, we stand a chance of making this better. This will make it easier for the other bits of government, including local government, to work. The whole of civil society can benefit. However, if we are talking about healthcare, the thing that gives someone a chance of enjoying their life is much easier if they have good health; it is much more difficult if they do not. We are going to have to take more positive steps. As has already been said, if we are obsessed with handing out pills in a certain way and concentrate totally on the overly high demand for acute services, we are never going to get there. I hope that, today, we will start to see this Government’s thinking on this subject, as well as that of others who are not in power at the moment.
Lord Crisp (CB)
My Lords, I congratulate the noble Lord, Lord Scriven, on his excellent speech. It was good to hear him take on the big questions in terms of what this is all about, what it is for and where we are going. He reminded me of my friend, who said this to me the other day: “Did you know that primary care is based on a 1948 business model? What else in our society is still operating on such a model?” The noble Lord also reminded me of something that is very close to my heart, having spent the past 17 years working on health in African countries: how much we can learn from people who do not have our resources, our baggage of history and our vested interests. He made a strong point about the importance of investing in primary care and community care to move the whole system on.
I want to reflect on the people side of innovation and improvement, as well as on some of the innovations of recent years; there have been some massive innovations in recent years. I also want to talk about some of the barriers to this sort of innovation. Let me start with a few reflections on the past. The last time the NHS was in serious trouble was at the end of the last century; I became chief executive and Permanent Secretary at the Department of Health at the beginning of this century. In that period, a number of big changes were introduced. Some of them were service changes. We tried to get waiting lists down—does this sound familiar?—and worked on best practice in ophthalmology and orthopaedics, separating elective and emergency orthopaedics. It all sounds quite familiar in terms of the sorts of things that were being done but, importantly, these things were changing the way in which people went about doing their jobs. It was not about some wonderful, whizz-bang technology coming in from outside, although technology helps; let us be clear on that. Good knees and hips—the joints themselves—were important as part of this, but it was about people.
Interestingly, we also introduced a number of policy changes. One was about offering patients a choice: if they had waited more than six months, they could go to another hospital. We also introduced competition, with South African units coming in to do some work on elective surgery. I would be happy to show the Minister the graphs I am holding, but the really interesting point is that you barely had to have a South African doing three eye operations before there was a change in the behaviour of the people in the NHS. Very few people exercised that choice and the competition was pretty marginal, but, frankly, the system changed quite dramatically. It was all about people’s behaviour.
That theme—people’s behaviour and clinical leadership—is very big. Let me turn to one of the most radical things that happened in those years: the introduction of nurse and non-medical prescribing in 2003. It was deeply controversial. The medical establishment was broadly against it, but it was the palliative care physicians who came and lobbied me about it because, frankly, they did not want to be woken up in the middle of the night. They knew that their nurses were quite able to change the dose of opiates. This measure was controversial when it was brought in in 2003, but I suspect that new medical students and doctors do not even know that nurses have not been prescribing for ever. It simply is not controversial now, yet many countries around the world, including most of our neighbours, do not allow anyone apart from doctors to prescribe. This was a big strategic change, and it came from clinicians.
Another change that has come from clinicians—this time, much more recently—is social prescribing. Again, it is something on which the UK is very much leading the way around the world. There are big and fantastic changes coming through from the people within the system and linked to it. It is really important that we acknowledge this. Some real, current examples of this include the virtual wards that are springing up all over the place. Again, these are examples of people inventing new ways of handling the system; things are very much helped by technology there.
What I want to touch on goes back to my point about learning from Africa. In the borough of Westminster, in 2021, community health workers modelled on the Brazilian model—not the African model—were introduced. Community health workers are local people who know their community and visit every house in their area once a month. They talk to people about health, they listen to them about health and they explore their health issues, after about six months’ training. It turned out that within six months there was a big increase in the uptake of immunisations, a big increase in screening and health checks and a reduction in unscheduled GP appointments. It was concluded that they were very effective at identifying unmet need, co-ordinating care—a very big issue—bridging health and social care and so on. From having four community health workers the borough of Westminster now has 30, and the programme is expanding at Bridgwater, Calderdale and Cornwall.
Two things about this are worth noting. This came about because of a British doctor, who is now at Imperial, who was working as a GP in Brazil. He brought this back with him to this country and spent years developing the ideas about how it would work. It would not surprise me at all if in 15 years’ time the front line of a lot of primary care was community health workers and then nurses and then doctors—a really radical change of the sort that the noble Lord, Lord Scriven, was talking about. So, there are big changes happening.
Outside the health service, too, there are non-health actors, such as the City Mental Health Alliance with the big companies in the City of London—all about nature and gardening, which I am sure noble Lords know all about. There is the Daily Mile in schools where teachers and pupils run a mile every day. There are 15,000 schools in the UK and many more globally doing that. So there is an awful lot of innovation and creativity, and these are all about passionate people making change.
It is true that the system needs external challenge from time to time; it must not get too cosy. But it is important for any Government to back their people. It is not always easy. Politicians, I know, of all parties are in a hurry and trying to push people into making change, but these innovations have basically come from within the system, from people who understand the detail. Understanding the detail is really important here, because it is easy to have big ideas about how things may happen. Too often, politicians will be talking about reform, when really they should be talking about evolution and taking people with them. Reform is something that tends to be done by you to other people. I think it is really important to get behind our health leaders and health people in all places, including the Derbyshire dementia team in Chesterfield, which I was talking about in Oral Questions.
Particularly at a time when people are exhausted—people have talked about a global epidemic of exhaustion in health systems—and demoralised, and there is a lack of vision around the world about what health services are, which the noble Lord, Lord Scriven, raised, there are some important things about the attitude towards where we seek innovation. None of that should detract from the extraordinary technological and scientific advances: targeted drugs; improvements in breast cancer treatment; the phenomenal changes in children’s cancer over the years; the enormous development, in my time, of catheter labs; how heart conditions are being dealt with differently; robot surgery; and so many more extraordinary things that we are able to do already compared with 15 or 20 years ago. We need both parts. We need technological innovation as well as human.
Let me now turn to the barriers to innovation on the people side. First, I will kick off with one of the issues: the financial rules, the constraints landing on our clinicians. I received a tweet—which I will not attempt to read on my phone in case it goes off wrongly—from a GP two days ago. He is somebody I know who does a lot of innovative work. He says that for four years he has been a clinical director of an ICN, and he thought that would be where he could make change happen, but he found it was about governance—a point the noble Lord, Lord Scriven, talked about—and that the financial rules meant that they kept returning to the GP contract, with all its constraints. The stuff they wanted to do was more community-oriented, inventive and innovative, about actually helping people with their health—to take a point from the noble Lord, Lord Addington—as well as with the immediate problem that they may have come into the GP surgery with, but the financial systems were getting in the way. I think that is a really big problem across the entire NHS.
The second problem that I want to talk about is that I get lots of people talking to me about the NHS, even though I left it 17 years ago, and the biggest complaint I hear is about the lack of joined-up behaviour. I mean joined up not between departments but between primary care and secondary care, or between the guy dealing with your knee and the guy dealing with your head or whatever—that whole issue of communication. Technology can help with that, no doubt at all, but we still have examples where people are using different record systems—the GP is using a different record system from the dementia care team, to go back to that particular story—and governance often militates against people working together effectively.
The final issue is the attitudes, behaviours and, underlying those, professional education—how people have been brought up within the system. The noble Lord, Lord Scriven, is quite right that we should be thinking 20 years ahead about what the jobs are going to look like. That means we need to change professional education profoundly. I know a lot of people are thinking about it, but I do not know that people are doing it.
We from the All-Party Parliamentary Group on Public Health recently published a report on this with a great title, not necessarily the best thing about it: Probable Futures and Radical Possibilities. We were saying, “Having looked around the world, this is what the future looks like and this is some of the radical change”. It picked up, and I am going to pick up, four points. The first is on technology:
“Science, technology and data will determine much of the framing and the language of health, shape how health workers think about health problems and possible solutions and how they act”.
It is going to be fantastically important and a much bigger bit of all professional education for the future.
The second point, which we heard a lot from young doctors in particular, was about the things not on the medical education agenda. There was no preparation around social prescribing. There is a great Beyond Pills campaign being developed by younger doctors and the College of Medicine. They are much more interested in a biological-psychological-social model than a purely medical model. Big changes are needed, and these are young people making these arguments.
The third point is on a set of skills. These are the so-called soft skills because they are difficult; they are the ones about teamwork, influencing people, relationships, participation and improvement science. It is worth remembering that in healthcare, as everywhere else, relationships trump systems. That is how you get around the systems and make them work. It is about learning about those soft skills.
The final point was that an awful lot of young people within the system—and this is around the world, not just the UK—feel trapped looking at a future of AI, technology, protocols and tougher management regimes, wondering what it will mean to be a professional in the future, feeling that they are just going to be turned into technologists, technicians, rather than the professionals of an older generation that many of us would recognise. They argue that there needs to be a much greater emphasis on relationships creating health; health workers as agents of change; facilitating change in patients, organisations and society; and being curators of knowledge.
So I would ask the Minister, in conclusion, whether he accepts that there needs to be more attention given to the financial rules guiding people’s behaviour in practice, particularly around primary care, but, secondly, to have a thorough look not just at numbers of healthcare workers but at the professional education that shapes them over so many years.
Baroness Bennett of Manor Castle (GP)
My Lords, it is a pleasure to take part in this select but very interesting debate, which is small in number but rich in content. I thank the noble Lord, Lord Scriven, for securing it. I will take a different approach from that of other noble Lords so far—perhaps a slightly stereotypical green approach. While we are talking about the current performance of the NHS and innovation, I will focus on the NHS’s environmental impacts.
The noble Lord, Lord Scriven, said that we have a 1940s health service in its structures and systems. We are in the 21st century and in a climate emergency and nature crisis, consideration of which has not been built into the system. I will major on aspects related to the comments made by the noble Lord, Lord Addington, about the centralisation of the system. Indeed, the noble Lord, Lord Crisp, was just talking about that and about how it prevents innovation and people taking action.
Let me do a little frame-setting. The NHS is responsible for 5% of the UK’s climate emissions and 40% of public service emissions. NHS England has a large focus on carbon emissions. Interestingly, NHS Scotland is leading on antimicrobial resistance and dealing with that area of environmental impact, and NHS Wales is focused on the environmental determinants of health and taking that approach. Each NHS can learn from the others, and a more joined-up approach is desperately needed. As I will come to, in Europe there is a lead on the impact of general pharmaceuticals on the environment, and we are not joined up with that at all.
The noble Lord, Lord Scriven, approached this in a positive way. I will do the same, in some places by highlighting success stories. The NHS has a net-zero carbon target by 2040. All NHS England estates now use 100% renewable electricity and 99% of waste is diverted from landfill. There are issues around incineration, but obviously there will always have to be some of that. It is worth stressing how much money this has saved the NHS, with a cost saving of £36 million and a £10 million investment in one year in energy-efficient technologies having positive impacts.
Slightly less obvious is an exciting development on which Scotland is leading the way and NHS England is following. Scotland has banned the use of desflurane, an anaesthetic with a global warming potential 2,500 times that of carbon dioxide. NHS England will be banning it in 2024. This is one of the leading ways in which thinking about the negative environmental impacts of medicines is happening. There is also an exciting new plan being developed for reducing the carbon impact from the use of inhalers. Much is happening, but everyone agrees that much more must happen.
I want to focus on an area that I have been majoring on since 2020, when we began debating the Medicines and Medical Devices Bill: the impact of pharmaceuticals on the environment. I saw the noble Baroness, Lady Cumberlege, in her place earlier, who wrote the very important report, First Do No Harm, which still needs to be implemented. When we think about the use of pharmaceuticals in the NHS, we have not thought sufficiently about the harm that they are doing.
What I am about to say draws heavily on a meeting I had recently with the pharmaceutical industry and my British Society for Antimicrobial Chemotherapy senior interns. I also worked with Paul-Enguerrand Fady, who is working with the Foundation to Prevent Antibiotic Resistance, which is based in Stockholm. Paul-Enguerrand is working here in Parliament, and I would urge anyone who is interested in antimicrobial resistance to get in contact. A whole series of events is being held to inform parliamentarians about this, and there is a chance to learn cutting-edge science with that.
From this meeting, I learned about the PREMIER project, a multi-disciplinary consortium of 25 public and private sector groups across Europe, proactively working to manage the environmental impact of general medicines, especially those with limited data availability. It is exploring ways to incorporate environmental considerations early in the drug development process to steer the development of new drugs. It aims to establish a new European standard of environmental protection and reassurance, for patients and society at large, that medicines are increasingly safe for the environment. If the Minister is not aware of this project, can he make himself aware? This is a Europe-wide project. I very much hope that NHS England will be following on and adopting this, not seeking to go it alone in an area where clear leadership is already happening. I do not expect an answer today but can the Minister look into that and get back to me on how the Government are looking at the outcome of that project?
I point out that the PREMIER project is working only on general pharmaceuticals; it is not working on antimicrobials or endocrine active molecules. Potentially, the UK Government could take a lead in ensuring that this project is broadened to include these crucial pharmaceuticals which we know are having a big impact on our environment and our environmental health. It was suggested at this meeting that there is a role for the Government Office for Science in promoting such connectedness in its position as an apolitical, evidence-based organisation. Being cross-departmental, it helps in focusing on systems thinking. The Government potentially have a convening role here to work with a variety of stakeholders. Can the Minister consider how they might take a role in that area?
I said that I would focus on some positives, and I noted that NHS Scotland is very much leading on the impact of pharmaceuticals on the environment. I draw the attention of the Minister to a project in the highlands. NHS Highland got a £100,000 grant from the Medical Research Council to develop a framework to reduce environmental pollution from healthcare practices. This is the first time that this has been done in the UK. Its leader is Sharon Pfleger, a consultant in pharmaceutical public health working with the University of Nottingham and the University of Highlands and Islands. This builds on the work of the cross-sector One Health Breakthrough Partnership, which has a data visualisation tool that helps to understand the link between medicine use and the presence of pharmaceuticals in the environment. I draw the attention of the Minister’s department to that.
Having looked around these islands I see that Wales, as I mentioned, is leading on environmental determinants of health. The Welsh NHS Confederation produced an interesting response to a Climate Change, Environment and Infrastructure Committee consultation on the Environment (Air Quality and Soundscapes) (Wales) Bill. I urge NHS England to contribute to cross-governmental working in this way. It is a very interesting model and we need to see this happening.
I have praised Wales and Scotland, so I should find a project in England to praise and focus on. Some work is happening in Cornwall. I draw here on the work of Roberta Fuller, who is head of hospital reconfiguration at the Women’s and Children’s Hospital at the Royal Cornwall Hospitals NHS Trust. Ms Fuller is working on how to ensure that a new hospital meets the best possible environmental standards. Drawing on the comments of the noble Lords, Lord Addington and Lord Crisp, I quote a paragraph from Ms Fuller’s reflections:
“What will it take to move away from traditional top-down funding allocation towards the kind of cross-industry partnering and thought leadership needed to meet these extremely challenging climate goals?”
Empowering people must be at the heart of tackling the issues that I am talking about, but of course there are so many other issues.
Finally, I will reflect a little on innovation. We have heard the word a great deal from the Government in recent weeks. I am afraid that, very often, when we hear members of the Government talking about it, they are talking about inventing new products that people will make profits from, usually involving shiny new things and, indeed, new pills. Of course, we know that the kind of innovation that I and pretty much all speakers in this debate have been talking about is about doing things differently and more smartly, and operating in ways that acknowledge the One Health paradigm: that our health is entirely dependent on the health of our environment. I would love to see more analysis and understanding from the Government that this is innovation. Innovation may, dare I say it, less directly involve GDP: you are not selling things but improving the public health of the population. We all know about the productivity crisis, the labour shortage and all the problems arising from the absolutely parlous state of public health in the UK at the moment.
In that light, I want to take a step away from the environment side to focus on an issue raised by the noble Lord, Lord Parekh, about the problems of obesity and the threats that it presents to our health. We have been talking about obesity, and it has been almost impossible recently to open a newspaper without seeing talk of the new Wegovy and these other weight-loss drugs. Newspapers have been quoting NHS sources suggesting that, eventually, 12 million people might be treated with Wegovy and similar weight-loss drugs in the NHS. I find that statistic truly horrifying. These are very new drugs, and we have very little idea of how long people might have to take them and what the long-term effects are: they simply have not been around for very long.
Yet, at the same time, we have Dr David Unwin in Southport. He has been an absolutely huge pioneer, starting from the grass roots up, in working to reverse type 2 diabetes. This was thought impossible until recently. What is interesting is that, reading accounts from him, he credits the initial impetus as coming from one patient who said to him, “Why have you been prescribing this drug for me for 10 years when I went off, researched for myself and found that I could change my diet?” Through diet reversal, this patient no longer had type 2 diabetes. We had one patient talking to one doctor, who started to innovate. This is starting to be rolled out around the NHS, but why are the Government not trumpeting it from the rooftops? When we hear the Prime Minister talking about innovation, would it not be great if he were talking about innovation in terms like this? This is a home-built, British innovation done in the grass roots—not based in a university, nor based in Oxbridge, and perhaps that is why we are not hearing about it. But we need to hear far more about this kind of innovation and empower much more of it.
On which line, I will finish with a reflection. I have talked about this ever since I came into your Lordships’ House, virtually. This is a request for innovation in government rather than directly in the NHS, and the Minister has heard it from me before. I am sure that he and all other Members of your Lordships’ House have noticed the strong media focus in recent weeks on the health impacts of ultra-processed foods, which are very clearly causing massive costs to our NHS. The Government have continually declined to acknowledge ultra-processed foods as a category, despite the fact that the Welsh Government, the WHO and many other groups around the world do. My request to the Minister is not to give me a total government turnaround today, but I will ask him whether he will commit to going back to the department and talking about where the latest science is on ultra-processed foods. This media focus has come from the publication of one book, but there are new peer-reviewed research articles coming out every week about the issue.
Lord Turnberg (Lab)
My Lords, I am extremely grateful for being able to speak in the gap. May I say how much I resonated with the speech by the noble Lord, Lord Scriven? I will follow him by talking not about the problems of the NHS—there are far too many of those—but about three possible innovations that might help.
The first relates to the integration of services within a locality. An innovation was introduced by David Dalton in Salford Royal Hospital and the whole town of Salford, with a population of 250,000. He arranged to oversee the care not only in the hospital but in the community. He employed GPs, set up the social care requirements, some social care homes and the mental health services. It was all under his control, and the local authority gave him the funding to do it. He did it locally. This was local innovation: local development of an integrated service with patients’ records available to all those involved in the care, including pharmacists. It was a remarkable innovation at the time. But it has not been followed to any great extent. There is lots of talk about integrated systems boards, and so on, but we need more of that sort of arrangement.
Second is public health and the preparedness for the next outbreak of a pandemic. Many years ago, probably before the Minister was born, I was chairman of something called the Public Health Laboratory Service. It was disbanded in 2004. It was changed to Public Health England and has had several other iterations since. One of its main attributes at the time was that it had a network of peripheral laboratories dotted around the country in every district, with specialists in public health. They detected outbreaks of E. coli infections, testing the water and the food. They were there to detect outbreaks wherever these occurred in the country and reported them straight back to the central laboratory in Colindale. In that way, we had a network that could detect and deal with infection as it occurred, wherever it was in the country. Unfortunately, it was a Labour Government who pruned the Public Health Laboratory Service and removed the network of laboratories that we had around the country. My second plea is therefore for the Government to reintroduce a service of that type, which involves peripheral laboratories.
Finally, the third point I wish to make is one that I have banged on about for some time, and which the Minister is probably bored of: social care, and the ability to give social care workers the respect they deserve by giving them career prospects, training, graduation and qualification. My time is up, but those are my three points.
Lord Allan of Hallam (LD)
My Lords, I am very grateful to my noble friend Lord Scriven for creating the opportunity for this important debate and for introducing it so well. I can also call him my noble neighbour, as we were previously both elected representatives in Sheffield. In fact, we are so neighbourly that the places in our pantomime names—the “of wherever” bit that we get in our formal titles—are adjacent to each other: Ecclesall in my case and Hunter’s Bar in his, for those aficionados of Sheffield neighbourhoods.
The theme of the debate invites us to consider the current challenges and potential solutions, and I will try to do that in my remarks. There are various ways to describe the state of health and social care in this country. Words such as “crisis” are in common use. Naturally, there is a party-political element to the choice of adjectives that we use, with those in government tempted to play things down and those in opposition to talk them up. In the spirit that my noble friend set out of trying to be more objective in this debate, I will try to use some factual descriptions of the current state of affairs, deliberately avoiding emotive language, that I hope will resonate on all sides of the House.
First, it is clear that health and care services are not meeting many people’s reasonable expectations. Too often, they find that they cannot access services that they believe are necessary for their well-being. In some cases, the services are not available at all, while in others they are there but only after an excessively long wait.
Secondly, and related to the access question, we do not have enough people employed in health and care roles to provide timely services of all kinds in all parts of the country. Many services depend on people having skills honed through years of education and practice. If the right staff are not there, these services simply cannot be delivered.
Thirdly, and related to the staff shortages question, there is poor morale in many parts of the health and care system, which is making it much harder to retain staff and affecting the motivation of those who choose to soldier on. The facile response to the morale question is to say that we should stop talking the service down, but that is to miss the point that there are genuine concerns about pay, work-life balance and career progression, which would affect any worker in any sector. Health and care workers are not immune.
It is possible to both praise the service and its staff and to raise concerns that it is not currently meeting the legitimate needs of its workforce. The focus of the Government has to be to address all these foundational issues, ensuring that supply can meet patient demand, building up the right skilled workforce and creating the right conditions to motivate staff.
Members of this House rightly raise questions in all of these areas across the broad range of health and care services each week. We will continue to press the Government until we see them deliver real improvements. Even if they deliver real improvements, we will want to keep on pressing them because we do not want them to feel complacent and because long-term demographic changes mean that, whoever is in government, they will need to keep running just to stand still and will need a super-human effort to get ahead of the curve.
This brings me to a fourth assertion and the one I want to focus most of my remarks upon: we will fail to deliver the healthcare that people need and deserve without introducing significant innovation into the NHS. That has been the theme of so many contributions today. However, this has to be the right kind of innovation. It is not an alternative to increasing investment in health and care but a complement to it.
There is a saying that if you only have a hammer then everything looks like a nail. To reinforce the point made by the noble Lord, Lord Crisp, I think about structures and legislation, and the hammer that we have as politicians is to pass more laws. We have seen successive Governments seeing innovation in Bills that create new structures for health and care but do not necessarily deliver wider innovation than the structure. We can all hope that these structural reforms will deliver. I know the current Government place a lot of store in the integrated care board model that is currently bedding in. However, the fact that restructuring happens repeatedly suggests that it is not enough to deliver the upgrade we need. The noble Lord, Lord Turnberg, reminded us that more can be done through better integration. That happens in some parts of the country but it is not spreading everywhere.
Others have spoken about a range of areas of potential innovation, which I hope the Minister will agree are worth exploring. My noble friend Lord Addington was right that we need to think about how health and care is dealt with across government. Departments considering things such as our sports, education or environmental strategies equally have a role to play in promoting health and care. Other noble Lords have brought other areas of expertise to bear. The noble Baroness, Lady Bennett, talked about the environmental challenges and some potential opportunities.
It is apparent that there is no shortage of ideas for how we could innovate our way to better health and care outcomes, but there seem to be systemic barriers to ensuring that innovations are taken up across services. I think that has come out in this debate, where we have heard that some of the examples of good practice are isolated examples rather than things which have become standard practice.
Like other Members of the House, as I was preparing for the debate I was contacted by a range of organisations that are thinking about innovative solutions in diabetes care, ophthalmology, cancer research, virtual wards—the list goes on. It is great that we have those ideas, but in this debate we need to think about why those ideas are not becoming standard practice. I was also fortunate to participate in a round table recently organised by someone who advises me, Peter Lacey of the Whole Systems Partnership. He brought together experts in different fields across health and care to pitch excellent ideas for how we might make real changes. I was impressed by just how much thinking there is out there.
We also read every week of projects bringing in new technologies such as AI. I accept fully my noble friend Lord Scriven’s point that it is not all about the technology but about the people, and again, we see these instances of pilot projects. I was reading just this week about the use of AI to detect breast cancer in Aberdeen. We are told that this can make a huge difference today, yet I fully expect when I read those stories that, in a year’s time, those projects will still be isolated to the particular trust that has brought them ahead.
I have a particular interest in how the innovative use of information technology might create step-change improvements. I want to introduce some of those ideas into the debate, but not because they are the most important. I am fascinated by examples such as that of the community health visitor that the noble Lord, Lord Crisp, raised. All those things are fascinating but it is sometimes helpful to talk about the things you know about the most. In my case, I have some expertise in information technology.
To be very clear from the outset, this is not about building more apps but primarily about ensuring that data and information can flow between people and services in ways that will add the most value to all parties. If noble Lords are interested in the argument for why we should focus on good service structure and design rather than just building more apps, I recommend an article from as far back as 2013, by Tom Loosemore, that the Government Digital Service called We're not ‘appy. Not ‘appy at all. It recommended that the Government hold back on seeing the solution as simply another app on your phone. Anyone who deals with the NHS will find, as I have done, that they have a whole folder on their phone of the different apps that different parts of the NHS have told them they must use to contact them. Some are good, some not so good, some get integrated and some do not, but it is not about the apps; it is about the flow of the data.
In the spirit of bringing positive ideas to the debate, an example of the kind of tool that is going in the right direction is a service called Patients Know Best. Other noble Peers may benefit from it if they live in the right parts of the country, because I understand that it is available only in certain health trust areas. This provides patients with immediate access to test results, with helpful contextual information so that, when they have a blood cholesterol test, they can see the result as soon as it is processed by the lab and go and get information about what that result means for them. These kinds of services should be standard practice everywhere; if someone has a test done then there should be secure online access to the results as a matter of course. Yet as I said, I understand that my access to that service is dependent on the part of London I live in, and people who live further down the road may not have access to it. I am curious about the Minister’s thoughts on why services such as these are not universally available.
The second innovation that has potentially huge value is the development of trusted research environments for health data. It is often said that a fortunate by-product of the fact that we have a unified NHS is that data about health activity and outcomes is more consistently available than in other countries, where it might be scattered across small and competing providers. Although we have our own issues in relation to how usable the underlying systems are, our unified national structure provides a good starting point in being able to pull together large-scale datasets.
One of these research environments is the OpenSAFELY.org project, which provides access to GP data not by taking it and sending it off somewhere else but by having infrastructure in the data centres of the main GP record providers so that researchers can access that data securely. We should be making more use of services such as that, having built them. I understand that it is not the universal access method; there are still plenty of people doing research using alternative methods and we have yet to get to a point where the innovation has become standardised.
That brings me to my final point, which overarches all of these areas—tools such as those patient tools and trusted research environments, but also good practice, such as community health visitors and other examples that have been raised. It is the question of how we ensure that innovation spreads. The way innovation spreads through the NHS at the moment is neither fish nor fowl. There has been a reluctance to dictate from the centre, under the assumption that market forces are somehow necessary to drive innovation, yet we do not see the best products and services winning as we would in other markets.
By way of an example, look at how the smartphone market developed; it was ruthless. Products from former giants such as Nokia, BlackBerry and Microsoft were beaten into submission by services from Apple and Android, the services that we all use today. There are bigger questions about competition that stand outside this debate, but the outcome we have seen there is the ubiquitous adoption of some very capable devices. By comparison, it can feel as if some parts of the NHS are still running on Nokia and BlackBerry while others are running ahead with their much better smartphones, and that produces very uneven outcomes. One thought I would like to leave the Minister with is whether there needs to be a different form of central direction to make sure that innovative services and models are delivered more rapidly.
At Oral Questions earlier we had a very good Question from the noble Lord, Lord Crisp, about a palliative care service developed in Derbyshire, and the Minister said, “We want all ICBs to do this”. It sometimes feels as if there are plenty of carrots on offer but insufficient sticks. What happens when a service is available, when we know that the technology is there simply and easily to introduce something such as immediate access to blood tests, but some parts of the country are not choosing to adopt that? What mechanisms may be used to encourage—and, to go further, require—that take-up to happen?
Again, I point the Minister to previous examples in which the Government Digital Service has existed not just to produce standards and say, “Here are the standards; go and do it”, but has had strong political support and would use much more persuasive measures to get different parts of government to adopt the latest thinking around digital. That is not exclusive to digital; it is a much broader question.
There is a need for a real sense of urgency in rolling out innovations in the health service, whether in technology, people, drugs or delivery models, if we are to have any chance at all of getting aligned with, never mind ahead of, the demand curve. I believe the Minister shares that sense of urgency. Perhaps he is not yet institutionalised enough to have given up on the idea that rapid change is possible. I hope that today he can offer us some glimmers of light that might encourage us to believe that change is possible. Again, I thank my noble friend and neighbour Lord Scriven for creating the framework for this interesting debate.
Baroness Merron (Lab)
My Lords, I am most grateful to the noble Lord, Lord Scriven, for securing this debate and giving us the opportunity to think about the link between current performance and innovation. I am also grateful for his introduction of the subject before us.
The noble Lord, Lord Crisp, and other noble Lords were absolutely right to remind us that innovation is about not just technology, important though that is—I will come back to that—but people, their practice, their professionalism and the way they work together. I hope the Minister will bear that in mind, because we are going to come to the issue of the workforce plan, which we still await.
A number of noble Lords have made the point that they have resisted talking about the difficulties faced by the NHS, but I am not going to resist. While the Minister has had a break, we must return to that subject because the fact is that the NHS has just not been able to meet many of its pledges—for example, on maximum waiting times—in recent years. The noble Lord, Lord Allan, made reference to the gap between the expectation that people have of the NHS and the delivery that they experience. We have raised that many times in this Chamber, and it is not just about expectation; it is also about people’s absolute need. It is more than disappointing that so many legitimate targets—which were set for a very good reason, which was to provide the best kind of healthcare—have just fallen by the wayside.
At the beginning of the year, the number of people on a waiting list for hospital treatment rose to a record 7.2 million. That number consistently rose between 2012 and 2019, and has risen more quickly since early 2021. I hope the Minister will resist constantly blaming the pandemic. It is of course true that the pandemic exacerbated waiting lists and has created many new challenges, but these problems existed before the pandemic and it would not be right to hide behind it, particularly when, for example, the 18-week treatment target has not been met since 2016.
The percentage of patients who have waited more than four hours in hospital A&E also rose consistently between 2015 and 2020, with a new record high reached in December 2022. We have discussed ambulance response times in this Chamber many times. These too have risen, with the average response time to a category 2 call in December 2022 standing at over one hour and 30 minutes, when the target was 18 minutes.
On cancer waiting times, targets are repeatedly missed and performances in April were among the worst on record. To give just one example, in April the 62-day target of 85% was not met, as only 61% of people started their treatment for cancer within 62 days of an urgent referral. This means that some 5,200 people who started treatment for cancer in April waited longer than 62 days after an urgent referral, when we all know that speed is of the essence.
In all this, my noble friend Lord Parekh and other noble Lords were right to say that there is much concentration on hospital care. Hospitals are of course a key part of the infrastructure, but we need to have more focus on primary care and to see joining-up—not just across government but, as noble Lords have said, across the whole NHS, along with social care. Noble Lords also spoke rightly today about the importance of prevention. The noble Lord, Lord Addington, and others raised this; we have to put far greater emphasis on prevention.
It is true that there has been a number of innovations and they are very welcome, but they are small fish when we compare them with the big picture. When we look at the revolution taking place in medical science, technology, working practices and data, we are missing out on the potential to transform our healthcare. There is absolutely no reason why this country should not be leading the rest of the world in this field, but it so often feels as if the NHS is stuck in something of an analogue age and that it has been allowed to happen under the watch of this Government. The future of the health service has to see, as noble Lords have said, more care taking place in the community. That would reduce the burden on hospitals; it would also allow patients to receive healthcare in their own home or close to home. But a slow adoption of technology has worked against this, as has the lack of joining-up within the system.
In his welcome intervention, my noble friend Lord Turnberg gave examples of both existing and previous practices that could be called upon. He also referred to the importance of having higher standards and a higher regard, and reward, for social care workers. If we are to support the development of social care and the healthcare system, those workers are absolutely essential.
The noble Lord, Lord Crisp, drew on examples of the network of community health workers in other countries, including Brazil. When I was an International Development Minister, prior to being a Health Minister, I also saw such networks growing and flourishing across African countries. They were built on trust, on locality and on harnessing people’s abilities and their links with communities. As the noble Lord asked, is it not interesting that that has inspired innovation in places such as Westminster and Calderdale? Who would have thought that?
I must say to the Minister that throughout the debate, I have been left reflecting that innovation, while it does exist, is patchy, and that is part of the problem. The IPPR estimates that, for example, the introduction of automation could be worth some £12.5 billion to the National Health Service by freeing up, among other things, staff time and by creating better productivity. Why are we not drawing on that?
I will refer to some missed opportunities, and then perhaps the Minister can explain why we find ourselves in this position. There are now tools which can map radiation therapy on to cancer cells and avoid organs more precisely than can an oncologist working alone. They do that in seconds, rather than the hour it takes a doctor. This is standard technology, used across the United States. However, just one in three radiotherapy planning centres in England uses this technology.
Between 1 million and 2 million mammograms are done across the UK every year. Although 96% will not find cancer, women are currently left in the dark for weeks, and even months, waiting for their results. The noble Lord, Lord Allan, suggested something quite obvious: why is there not a better technological means to notify people of their results? Why is there a hold up on mammograms? Because two clinicians are required to check them, and there is a workforce crisis. However, AI could rule out cancer-free screens in seconds, giving patients their results faster and freeing up clinicians to focus on the tests that display abnormalities. It has been rolled out across Hungary since 2021, but not across the National Health Service.
AI can also help to interpret chest X-rays, saving 15% of a radiologist’s workload. When combined with interpretation by a consultant radiologist, it could reduce missed lung cancer cases by 60%, but it has yet to be fully adopted by the NHS. Can the Minister tell us why?
We all know that staff shortages across the NHS workforce are not only a barrier to meeting important waiting times but also limit the NHS’s ability to adopt and develop innovation, in both a technical and technological sense, and a people sense. We have recently been told that the NHS workforce plan will arrive shortly—after many years of it not arriving shortly. Perhaps the Minister could again answer the question of when we will see it, whether it will be fully funded, whether it will ensure a look to the future and how it will deal with the immediate.
The NHS should not be lagging behind. It is a universal, single-payer service and it ought to be the best-placed healthcare system in the world to take advantage of changing technology and medicines. After all, what other health service can offer innovators a market of some 50 million patients and give the life sciences industry access to a diverse and large population sufficient to develop new medicines, in the way that our NHS can?
In drawing my comments to a close, I want to offer some solutions from these Benches to add to the points raised by noble Lords in this debate. On procurement, the NHS should identify the goods and services that should be purchased at scale and buy them at a discount. This would also cut out unnecessary bureaucracy and stop new technology being re-evaluated for years, while the world moves on and beyond. In clinical trials, I suggest that every trust could operate through a standard system so that the number of contracts needed is minimised and the administrative burden is eased across the system.
While I accept the point made by the noble Lord, Lord Allan, that apps are not everything, they are important and proper use of the NHS app could be made and extended. It currently has some 30 million users—that is a tremendous reach—but every patient should be able to see their medical records through it. They should be able to use it easily to book appointments, order repeat prescriptions and link to appropriate self-referral routes. When patients reach an age at which they should be screened or need a check-up, the app should alert them, just as we are constantly alerted by apps in other areas. If people are eligible for a clinical trial, the app should tell us.
For the NHS to be fit for the future, it has to make fundamental change and there has to be a different way of doing things. I hope the Minister will reflect on the debate today and take heart from the fact that we all want to see change, but that he has the responsibility to deliver it at present.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Markham) (Con)
I thank the noble Lord, Lord Scriven, and all noble Lords for what I found to be a very thoughtful debate. I hope to answer in the spirit engendered by all noble Lords but particularly the noble Lord, Lord Scriven. I will not be defensive, so I will not try to answer point by point but will try to lean in.
I will try to summarise the approaches, and I think there are a number. The first, as pointed out by the noble Lord, Lord Addington, is getting upstream of the problem. It is about prevention and how we can use primary care, be it through the example of Salford, mentioned by the noble Lord, Lord Turnberg, or Westminster, mentioned by the noble Lord, Lord Crisp, or Redhill, where, as I saw the other day, they are trying to identify those who need the most help and care in order to get ahead of the problem. Real prevention is better than cure.
Secondly, there is innovation. Yes, it is about technology, but it is also about people and culture and what we can learn. By the way, I think that is the hardest one. Thirdly, there is approaching this issue from the perspective of outcomes. When looked at from that end of the telescope, you often come up with a different approach; in that respect, I love the drone example. Fourthly, again as the noble Lord, Lord Addington, said, there is taking a holistic, society-wide approach to health. The saying that strikes me most in that regard is that health is one of the things we all take for granted, until we lose it. This leads on to my fifth point: what can we do to help people take control of their own health? It is so important to our whole welfare. What can we do to enable people to take control?
In my speech, I hope to talk through some of the thoughts, ideas and approaches that we are trying to adopt as a Government. I hope to offer some of those glimmers of light that the noble Lord, Lord Allan, mentioned. I will not pretend that it is a panacea that will solve everything, and I accept the challenges that the noble Baroness, Lady Merron, brought up. She will probably be pleased to know that I will not try to give a point-by-point defensive rebuttal, because she probably hears enough of that from me in Questions every day.
In the spirit of what we are trying to do, first, I completely agree with a number of speakers, particularly the noble Lord, Lord Allan, about contextualising the issue. We are already spending 12% of our GDP on healthcare. With an ageing population, where a 70 year-old patient will need five times the amount of treatment of a 20 year-old, and the fact that that population has grown by 33% in the last five years as a proportion, and with the problems of obesity and comorbidities, we know that that 12% will just go up and up unless we can really get ahead of the issue. As the noble Lord, Lord Allan, mentioned, we have to run fast to stand still. I fundamentally believe that, if we cannot transform and innovate, we are really going to struggle to see the NHS model being sustainable right the way through the 21st century; it really is that fundamental.
The good news is that we do have some early glimmers of light, so to speak. We have done a really good digital maturity assessment to see the state of different hospitals: to aid the rolling-out, we need to know what our start point is. We see that the most mature digital hospitals actually have 10% more output and are more cost efficient, and that is just things today; I will come on to talk about the new hospital programme later and how that can improve things further.
As for what we are trying to do as a Government, I want to talk through six things that we are trying to do to set down platforms to enable. The first thing is to support small companies to develop and deploy the new medical technology. I have seen many examples of the AI that the noble Baroness, Lady Merron, mentioned, and she is absolutely right. We know the scale of what it can do: we see a whole category of cancer-reading MRI AI-type devices that we are putting through their paces at the moment, for want of a better word. I will come later to how we will try to scale those up.
We are doing a number of things to support these small medtech companies. As I say, we have put £123 million through the AI Lab on 86 projects. Through the small business research initiative for healthcare, we have funded 324 projects for £129 million, and there is some early promise there. We are trying to back them early on, as I will come on to, but the problem is often not the original innovation or idea but its widespread adoption. I am sure we have all heard the joke that the health service has more pilots than British Airways, but how do we seek to roll things out?
First, we are backing small companies. Secondly, dare I say it, I am going to mention the app, in that we have a £32 million platform, as the noble Baroness, Lady Merron, mentioned, that offers an opportunity for companies and different solutions to reach the population. I announced just this week what we are doing in the space of digital therapeutics, with mental health apps and musculoskeletal apps that will be available to everyone, but what is also vital in this space, I firmly believe, going back to one of my early themes, is that the app allows people—excuse the saying—to take back control of their health. For me, that is a fundamental thing that we need to enable people to do. It is not just about booking appointments; it is absolutely about getting patient records.
To be honest, we need help there, because we do have opposition from some of the medical profession to giving access to patient records on the app. We have 25% of our GPs who are currently doing it, so you see certain areas where they are definitely benefiting from it all, but we see others where we still need to win them over. Let me put it politely that way. I firmly believe that what we are doing with the app—and we will see a series of new features being launched over the coming months—will give more and more functionality and power into the fingertips of the individual to really take control of their health in a way that people do with some of the financial apps. That is a fantastic opportunity that should really make a difference.
Thirdly, as the noble Lord, Lord Scriven, mentioned, I want to talk about the new hospital platform that we are building. It is not just about buildings; it is actually about the whole processes and technology. We are planning a parliamentary day on 18 July, where we will be inviting everyone to see the plans for what we are trying to adopt for the whole systems and processes. We call that Hospital 2.0. I know that the noble Lord, Lord Allan, thinks we could have been more creative with that title, so we are open to new ideas. As I mentioned before, the digitally mature hospitals are 10% more efficient. We believe that these hospitals will be at least 20% more efficient. That is not just 20% more productive, but probably most important is the reduction in length of stay that they can make as well. One of the statistics that struck me the most is the fact that older people lose 10% of their body mass each week that they are in hospital. In respect of some of the comments made about the importance of social care by the noble Lord, Lord Turnberg, of course the best solution is having people in hospital for as little time as possible so they can go straight back to their home environment. Around that, some of the innovations on the same-day emergency care, where as many as 85% of people treated that way, show a very good example of that.
With the new hospital plan, where we are looking for productivity gains of 20%-plus, my sincere hope from all of that is that, rather than us asking the Treasury for more money to build these hospitals, it will see those sorts of productivity gains and will be encouraging us—“How quickly can you build them? How many more can we have?”—because they really will have that transformational approach.
Fourthly, again, as mentioned by a number of noble Lords, including the noble Lord, Lord Allan, the 50 million patients we have are providing a data platform. Regarding a secure data environment, the plan is that the data will always be held securely in its place, but people doing clinical research will have access to that environment, so they will not be able to take it away but they will be able to do it in that environment where they can conduct the clinical research and start to see the results. Again, I see our job very much in terms of innovation, with us providing that secure data platform for others to be able to do their research on.
The fifth area—and I think this is particularly relevant to the AI field—is the regulatory environment and support. Again, we all know that AI has fantastic opportunities for innovation, but we also know that, without it being done in a safe and ethical manner, there are challenges there as well. We also know that it is a complex field, with the MHRA, NICE, CQC, HRA—we have an alphabet soup of regulators—to navigate your way through. We have tried to launch a one-stop shop web service so people can really understand how to navigate their way through and have all the information in one place.
I now come to the sixth, and probably the hardest, part in all this: how we get innovation adopted and scaled up across the system. There are many advantages to having 120 different hospital trusts, 42 ICBs and thousands of GPs, and that freedom can often bring innovation, but there are also many disadvantages in the scaling up and rolling out. We have seen many examples where you have a promising new technology with a small start-up company, and you say, “Well done, it’s great. Here’s the telephone directory—good luck”. A small company especially just does not have the resources and time to get out and scale up.
For certain technologies, we are trying to bring them to a central buying point and process. There are examples of where we are doing that already. Noble Lords will often have heard me mention the Maidstone flight control system, which arms the clinicians with information about what is happening across the hospital, what the 999 calls coming in are, where they are likely to need beds and what they need to free up, so that they can make on-the-spot decisions. We are scaling that up and rolling it out across multiple hospitals. We are looking to do that in a number of areas, where we think we can do things better from the centre. I do not pretend for one moment that we have all the answers, because rolling out and scaling up are some of the most challenging areas. One of the first things I learned on taking up this role is that the word “national” in National Health Service is probably not apt.
The rollout of the buying points is a key thing that we hope to do. We are also seeing the rollout of virtual wards, as mentioned by the noble Lord, Lord Crisp. On new technologies, I have seen things where you can monitor the electrical usage in the homes of people who need more support. This is particularly relevant for dementia patients. If you normally see a spike in their electricity usage at 8 am because they turn on the kettle to make a cup of tea, when that suddenly does not happen you have an early warning. Have they suffered a fall? Is there something we need to investigate? That technology lends itself to mass scaling, and those are the sorts of things we see promised in those early technologies that we look to roll out across the system. That is one of the biggest challenges.
I hope noble Lords can see in my response that I am not pretending we have all the answers but, taking on the spirit of the debate, we are trying to adopt and innovate. I thank all noble Lords for their contributions.
Lord Scriven (LD)
My Lords, I thank everybody who participated in this debate, including the Minister, for approaching this in the spirit of the debate’s framework, which was to concentrate not just on the problems but on some of the innovative solutions that can help to take forward not the health service but the health of the nation.
I will finish with a quote from a GP in south Cumbria, who said:
“I feel frustrated that I am working in a health and care system that increasingly fails to meets the needs of people. It is not fair for people to have to keep returning cyclically without us making a fundamental difference to the root causes of their problem”.
There are three or four things I want to take away from this debate and make sure the Minister really understands. The first is that the centre has to move away from an obsession with governance and actually support people a little more in terms of how to innovate. It needs to give people a little more space to evolve some of the issues.
The other thing is that this is about people, people, people. It is not necessarily about the big bells and whistles. The technology is fine, but if the underlying people problems still exist, no matter what app you get, that system is not solved; it just replicates on a digital platform the real issue that is going on behind it. Also, people’s experiences—I mean not just staff but real people, those we call patients—are really important.
My final tip to the Minister is sometimes to go to areas that do not have good practice. I did that when I was leader of Sheffield City Council. The Minister’s officials will want to go to the areas of good practice, but he should go to some of the areas where take-up or innovation are not great, because he will get a different perspective that will then help support the rollout. With that, I thank everybody who has taken part.