(7 months ago)
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Lord Patel
That this House takes note of the long-term sustainability of the NHS to be able to deliver comprehensive, timely and affordable health and social care for all, including options for systems of care and funding.
Lord Patel (CB)
I see noble Lords leaving. The debate will not be that bad. It has certainly emptied the House.
I am grateful to the noble Lords who are taking part in the debate. I look forward to their speeches, particularly the maiden speech of the noble Baroness, Lady Ramsey of Wall Heath; I wish her well. Several noble Lords—the noble Lords, Lord Stevens of Birmingham and Lord Darzi, the noble Baronesses, Lady Harding and Lady Watkins, and the noble and gallant Lord, Lord Stirrup—would have joined us, but other commitments do not allow them to do so.
I declare my interests. I am a fellow of several medical royal colleges and faculties. Importantly, I worked for 39 years in the NHS in its glory days. My comments will be based on comparing the current state of our healthcare system with 26 other systems that I have looked at. They all have some problems but, compared with more developed systems of universal care in Europe and the Far East, ours is severely strained.
On 26 April 2018, 6 years ago, we debated this exact Motion. There were 50 speakers and the debate lasted nearly seven hours, interrupted by a Statement on artificial intelligence, which mentioned how AI will transform healthcare. Today’s debate may well mirror that debate in 2018. What has happened since then? We have daily media reports of the demise of the NHS as we know it, and lots of suggestions for how to improve things. Public satisfaction with the NHS is at its lowest point; waiting lists are at their highest level; waits at A&E are long and harming patents; and there are huge inequalities in health and poor outcomes—I could go on.
After several reorganisations and reforms, including a seismic one in 2012, the NHS has not found the equilibrium that it needs. But the NHS is still capable of delivering superb primary, community and hospital care. Thousands of hard-working, resourceful and committed front-line professionals are prepared to go the extra mile, despite feeling undervalued. They need to be better supported and valued before they too give up. It is access to care that has become a major problem.
The current state of NHS is not because of some inevitable built-in decay; it is a system failure. It is the result of decades of political short-termism, a lack of long-term planning and an underinvestment in capital infrastructure and technology. The system lacks capacity, with fewer beds and equipment such as CT, MRI and PET scanners, and with a huge workforce shortage compared with other countries. We now have a workforce plan stretching to 2035, with no longer-term funding. We need it to work. I congratulate the Minister for getting 50,000 nurses in place, as the Government hoped to.
A lack of planning means that disease is diagnosed at a later stage, leading to poor outcomes. Modelling suggests that, by 2040, one in five people will be living with a major illness, which is upwards of 9 million people. Nearly 3 million people of working age will not be in work due to ill health. Not investing in health means greater pressure on the budgets of other departments. Anxiety, depression and chronic pain will be the main causes of ill health, which has implications for primary and community care.
Unfortunately, there is no silver bullet to reduce the growth in people living with major illness in the short to medium term. Diseases that affect millions, such as diabetes, cardiovascular disease, stroke, some cancers and chronic lung disease, are all amenable to either prevention or early detection. The focus needs to change to prevention and health, not just healthcare. We need to move from: “I am ill; I need to get better” to “I don’t want to be unwell”. Countries that have recognised this are seeing the benefits of higher life expectancy, people living more years in good health and being more economically productive. The system needs to change to make primary and community care a central part of our care system.
The current funding of primary care is at 8.4% of the total NHS budget of £192 billion, which is the lowest in eight years, and it employs only 154,000 of the total 1.3 million workforce. This proportion will need a significant increase to at least 20% or more if we are to see improved access to primary care. The traditional system of a single portal of access to healthcare also needs to change. To enable patients to have greater choice of access, community care will need to be staffed by a multidisciplinary team of professionals, including general practitioners.
An explosion in data, generated by patients and the health system, will drive healthcare through screening services’ early detection of markers of disease, such as blood pressure monitoring and hypercholesterolemia, to mention but two. Population and risk-based genomic screening, liquid biopsies, individual health data monitoring and so on will lead to early risk identification and detection of disease. Healthcare will be digitally driven, technologically enabled, personalised and patient-centred. Patients will be involved in planning and managing their own health. The best health systems in the world have strong community care, with a focus on helping people stay well.
From birth to death, health, healthcare and long-term care in old age is a continuum. If any part of it is not functioning, it affects the rest. The lack of a properly funded and organised social care system is having a huge effect on the NHS. We have had 28 years of kicking the can down the road. After seven policy papers, six consultations and four independent reviews, we have a social care system that is means-tested, needs-assessed and underfunded.
There is a lack of a workforce plan for a service that needs 1.5 million staff, with 2 million people still needing care—one-third of whom get no support. With a rise of 20% in working-age adults needing social care, this needs urgent attention. Capacity is getting worse, and public satisfaction with social care is as low as 13%.
Various options have been considered, including free personal care, the Dilnot cap and universal care. The best performing comprehensive system of social care is provided in countries with a long-term care insurance, or which is tax funded, based on the principle of social solidarity. People above a certain salary range pay throughout their lives. Without a solution to the funding of social care, the NHS cannot survive.
I now turn to the key issue of funding the NHS. Funding of the NHS has always been a rollercoaster, despite its link to the performance of the NHS. The planned budget for 2024-25 is £192 billion, an increase in real terms of 0.6% from the 2023-24 settlement but a reduction from 2022-23. According to NHS England, it will provide a spending increase of 0.25%. Over the parliamentary term 2019-20 to 2024-25 the increase has been 3% per year, but from 2010 to 2019 it was 1.4% on average.
Following the famous “expensive breakfast” in 2000—when Prime Minister Tony Blair announced on breakfast television an uncosted commitment that he would bring NHS spending up to the EU average—and the Wanless report, there was a multiyear increase in funding leading to better NHS performance. Waiting lists came down dramatically and health inequalities began to improve.
If the EU average had been maintained in the years that followed, the budget would now be £40 billion higher per year. Lack of capital funding—an average of £2.5 billion per year from 2010 to 2019—has led to poor infrastructure and a lack of equipment; it has not increased. Rising costs have led to calls for funding reform. Social insurance, some element of self-pay and hypothecation have all been suggested. Each has its own problem. Analysis suggests that a single-payer system is most effective in costs and complexity. The public seem to prefer a tax-funded system. What is important is that there is properly costed long-term funding that tracks GDP growth. Also important to note is that while measures of prevention and healthy living may make people live longer in good health, they will not cut costs. If cutting costs is a priority, a different model of care will be needed—but people may not live longer.
In conclusion, a sustainable future for both NHS and social care is possible, and with it a healthier population that leads to increased life expectancy and decreased health inequalities. It needs a long-term funding commitment, including in capital funding, and strong primary and community care with a focus on prevention and health. It needs to be digitally driven, connected and tech enabled, and to have a clear plan with timelines for its introduction. An overcentralised, bureaucratic system will not address the fundamentals of effective healthcare. This may well be the last opportunity for the NHS as we know it and as we want. If not, the public may well seek an alternative that could lead only to a two-tier system of care.
My question, in this election year, is to the Minister and the noble Baroness on the Opposition Front Bench: what plans does each party have to make the NHS sustainable in the long term? What support will the Liberal Democrat Front Bench give to make amends for the part it played in the reforms of the coalition years? I beg to move.
Baroness Blackwood of North Oxford (Con)
My Lords, I declare my interests as chair of Genomics England and Oxford University Innovation and a board member of BioNTech. It is a great pleasure to follow the noble Lord, Lord Patel, who is an eternal champion of the NHS and a great expert in these matters. I am grateful to him for convening today’s important debate.
As time is short, I will focus on the role of genomic technologies in future-proofing the NHS. From Crick, Watson and Franklin discovering the double helix structure to the Human Genome Project, the UK has long been at the forefront of genomic discovery. With the 100,000 Genomes Project we did something quite different—we drove that discovery into the heart of the clinic for patient benefit. Today Genomics England hosts the largest clinical whole-genome dataset in the world. Recruitment of this cohort was complete in 2018 but analysis is still ongoing, increasing the diagnostic yield all the time. In rare diseases this is over 30% and rising, while in some individual conditions, such as cystic renal disease, it is over 60%.
Each of these diagnoses is a life changed. One 10 year-old girl was admitted to intensive care with a life-threatening condition. It turned out that she had been undiagnosed with a rare condition for over 7 years with more than 300 secondary care episodes, costing the NHS over £350,000 to date. It took whole-genome sequencing to uncover a genetic deficiency and provide her and her family with a diagnosis at last, ending her diagnostic odyssey. Moreover, a bone marrow transplant proved curative. From sequencing to treatment in her case cost £70,000, just 20% of her pre-diagnosis healthcare costs. This sounds like an edge case, but rare disease patients have an average of 67 appointments over 75 months before diagnosis. For many patients this diagnostic odyssey is much longer.
That is why Genomics England was founded—to use the power of genomics to do better. Our aim is to change the fundamentals of healthcare delivery. We want to create a virtuous cycle by making genomics routine in the NHS and supporting frontier genomic research and discovery, and to continually replenish one of the richest genomic datasets in the world. In doing this we will create a return for participants through better diagnostics and therapeutics; a return for the NHS by boosting productivity and efficiency through stratification, screening and early intervention; and a return for the UK by increasing R&D investment and clinical innovation.
Genomics England now enables the NHS to deliver the world’s first nationwide whole-genome sequencing service for more than 190 clinical conditions across rare diseases and cancers. The service has supported more than 90,000 patients since its launch at the end of 2020 and is scaling fast. We ask patients for a specific consent to use their data for research purposes. Over 95% agree, and their data is stored in the National Genomic Research Library to enable cutting-edge research. The findings of that are then driven back into the clinic to improve NHS care. This means that the Genomics England structure is inherently translational by design; the heart of our mission is to drive long-term, sustainable improvements in the care of our participants and in the NHS as a whole.
We see research and clinical results flowing all the time: research at Great Ormond Street for children with blood cancers found that whole-genome sequencing was proven to provide additional information for diagnosis in 81% of cases, it changed the management of condition in 24% in cases, and it reclassified diagnosis in 14% of cases. Meanwhile, baby Oliver in Cambridge was born with a 6-centimetre tumour on his leg. Under the microscope it looked like an infantile fibrosarcoma and the standard testing was inconclusive, but with whole-genome sequencing it was confirmed as a benign myofibroma. This meant that baby Oliver was spared chemotherapy and surgery and is now happy and healthy.
We know that over the next decade data, analytics and genomics will transform healthcare by enabling personalised medicine. This means more effective and tailored treatments, better diagnostics and predicting disease susceptibility so that we can intervene earlier— possibly even preventing disease altogether. Earlier intervention and more targeted treatment not only improve patient outcomes but reduce the huge healthcare costs of ineffective treatments and side-effects. Multimodal genomic data that we are building now have the potential to cut the costs of drug development and improve population health management.
That is why at Genomics England we have launched three programmes designed to push the envelope of genomic medicine further into the clinic. We are diversifying the ancestry of genomes to improve equitable outcomes for patients; validating long-read and multimodal cancer technologies to drive earlier and more accurate diagnostics for cancer patients; and our Generation Study, a newborn screening pilot, is designed to end the diagnostic odyssey where it starts and explore options for supporting genomic-enabled prevention. The potential of genomics is immense, but to fully harness its power we must continue to invest in research, infrastructure and education to realise its full potential and truly make the NHS sustainable.
Lord Hunt of Kings Heath (Lab)
My Lords, I am very grateful to the noble Lord, Lord Patel, for opening the debate, and very much welcome my noble friend Lady Ramsey on the occasion of her maiden speech.
The noble Lord, Lord Patel, talked about the NHS being severely constrained, but we know that the NHS can work well. Fourteen years ago, the NHS was in rude health, with new hospitals, new services, and waiting times that had come down dramatically. In 2010, the British Social Attitudes survey reached the highest level of satisfaction ever at over 70%.
What have 14 years of coalition and Conservative Governments brought us? The latest survey, published three weeks ago, recorded the lowest levels of satisfaction since those surveys started in 1983, of 24%. Long waits have become the norm; access to GPs, dentistry and CAMHS services have become very difficult for many people; ambulance waits are outside safety targets, and social care is unreformed. As the noble Lord, Lord Patel, said, we have very poor health outcomes as well. If the NHS is to be sustained, it has to respond to health and care needs very different from those that existed in 1948. There are complex long-term conditions among a growing older population—yet the NHS at the moment seems woefully unprepared or, as the noble Lord, Lord Patel, said, it has not reached an equilibrium.
To turn this around, I agree with the noble Lord, Lord Patel, that we first have to start upstream, with a bolder preventive focus to reduce health inequalities and improve life expectancy. As my noble friend Lord Filkin, the noble Lord, Lord Bethell, and others say in their recent report, Health is Wealth, our nation’s poor health damages lives, communities and our economy. Then major surgery is required of the NHS. Wes Streeting has outlined a decade-long programme of modernisation, with plans to digitise massive amounts of NHS paperwork and to make proper use of the NHS app to give patients real control. What the noble Baroness said about genomics really fits into that model.
However, three major changes need to accompany this. First, we need a step change from the current overcentralised and bureaucratic NHS. As Nigel Edwards of the Nuffield Trust has said, we have a culture of checking, assurance, performance management and other manifestations of a controlling and low-trust approach, alongside a system with a very large number of priorities. I do not know whether the Minister is aware how much NHS England’s approach is despised and hated within the health service at the moment. I would suggest that that comes from the approach that Ministers are now taking to NHS England. It comes right from the top.
This has to go with the workforce. We need a fundamental change in how we treat our people working in the NHS. Bullying, problems of recruitment, retention and morale—these are everywhere in our health service. I have been fascinated to read the outcome of a King’s Fund and RCN project entitled Follow Your Compassion, which looked at the experience of 22 newly qualified nurses and midwives. The work that they do is high stakes, with significant and often disproportionate responsibility placed on them almost immediately after qualifying. Life, death and human suffering are everyday encounters, and the work of caregiving is emotionally demanding. But the overwhelming experience of participants was reported as their feeling unprepared, anxious, silenced and exhausted. You can have as many workforce plans as you like but, unless we get to grips with how our people are treated in the health service, you will never really sort the workforce problems out.
Finally, we must invest in leadership and management of the NHS. I remind the House that I am president of the Institute of Health and Social Care Management. Unlike the military and many private organisations and companies, the NHS does almost nothing to select, nurture and develop the next generation of executive leaders. Training and development are often sporadic, which, combined with the lack of a systematic appraisal, makes development and deployment of key talent almost impossible. The Government’s insistence on carving yet more managers out of the system at the moment is having a very damaging impact on their ability to take forward the kind of change that needs to happen.
If we do not sort this out, if we do not change the culture, if we do not put more trust in the NHS locally and if we do not sort out social care, all the other changes that we need to make will come to very little. This Government have now had 14 years; they have had their opportunity—it is time for change.
Lord Scriven (LD)
My Lords, what a pleasure it is to follow the noble Lord, Lord Hunt of Kings Heath, who like myself is a former NHS manager and who clearly understands the difficulties and nuances of the future challenge of the NHS. I am also thankful to the noble Lord, Lord Patel, for this very timely debate.
The current performance of the NHS worries many and therefore needs to be improved urgently before it can be a stable platform for us to rise to the challenge of the significant technological and demographic changes that will take place if it is to become sustainable. The NHS’s current performance is distressing to say the least, despite the gallant efforts of many staff within the system. People in need of care and treatment are unable to see an appropriate medic or professional, with some waiting up to three years just to get on the NHS dentist list. People are waiting in the back of ambulances outside A&E for hours, while people waiting for a cancer diagnosis are not getting access to timely treatment, which can be life threatening, and people in great pain and agony are waiting far too long for planned operations. The Government have allowed this to happen and now try to placate the public with a list of office-generated statistics and playing catch-up. It is not good enough. People deserve far better than this.
Despite this picture of appalling failure by the Government, this debate makes us think very carefully about the future of our NHS. I am sure that the debate will be framed around two themes: one is how to make the NHS more productive, efficient, and innovative, while the other theme will be the wider context of the demographic, economic and social issues in which the NHS will have to work. The reality is both these themes will have to be addressed for a sustainable NHS.
Time today is limited, so I cannot go into depth about what is required across both themes, but I shall throw these issues in as a starter for 10. The 1948 orthodoxy on which the NHS stands has to be addressed, if we are going to see an NHS that can meet future need. For instance, why do we have a fixed view which is over 70 years old of what a hospital should be? Why are emergency and elective services always in the same building? Is it time to think more laterally about emergency hospitals and elective hubs? The model of primary care needs to be questioned. Why have we had the same model and front door system for over 70 years? This needs significant change, for those who need significant primary care needs due to comorbidities and those who occasionally dip in and out of primary care. Maybe a different type of service delivery is required, as the integrated electronic health record takes hold, with no longer just one model of GP and primary care access.
As technology, robotics, AI and data-driven services become central in predicting, planning and delivering healthcare, appropriate leadership skills at all levels of the NHS will need to be addressed to maximise the potential of these issues, as well as to minimise the risks. Is it time to end the leadership model based predominantly on managing efficient siloed organisations by moving to leaders who are experts in maximising health gain and facilitating community action to bring about complex change?
Societal issues, such as housing, education and the environment will have to be addressed, as the NHS does not work within a vacuum. A population that is ageing with comorbidities, and the balance between the working-age population and the non-working-age population—and, of course, climate change—needs to be addressed. Some key issues that we need to think about across government to support the NHS maximising health gain are supporting people to age with dignity and independence, tackling deep-rooted worklessness, and an absolute laser-sharp determination to narrow the health inequalities, as well as having a long-term and fully understood funding formula for both the NHS and social care.
All this will take long-term, focused action by government and society. I am not sure that the siloed structure of central government can deal with these challenges effectively at present. The approach must be a community health-based model, to maximise healthiness and improve health outcomes.
One simple way of supporting this would be for the Treasury to set up designated funds that can be used in communities and the NHS to invest for health. That would break down the problem of pretending we can move existing NHS budgets, which are mainly sunk, fixed costs, into prevention and reducing health inequalities.
Talking of funds, it is vital, as the noble Lord, Lord Patel, said, that we sort out, once and for all, the social care crisis. The NHS can never be sustainable if, as a nation, we have not dealt with social care funding. After the general election, I think it is the duty of all politicians, from all parties, to sit down and work out a cross-party solution to this difficult problem that has been left for far too long. We need to take a different approach and think about some fundamental questions if we are to have a sustainable NHS.
Lord Crisp (CB)
My Lords, I congratulate my noble friend on his excellent speech introducing this debate. I am very much looking forward to the maiden speech of the noble Baroness, Lady Ramsey of Wall Heath, bringing her great expertise to bear on this issue. I declare an interest, I suppose, as former chief executive of the NHS in England and Permanent Secretary at the Department of Health between 2000 and 2006, when I had the privilege to work with three noble Lords who are taking part in this debate: the noble Lord, Lord Reid of Cardowan, as Secretary of State, and then successively the noble Lords, Lord Hunt of Kings Heath and Lord Warner, in your Lordships’ House.
I want to make three points about the major reforms that are required, and a fourth point on implementation. I shall state them briefly at the beginning, in case I run out of time. The three reforms follow very much from what the noble Lord, Lord Scriven, just said: that we are using a 20th-century model of service delivery for 21st-century issues, and that must change. The second point is that the Government need to create a cross-sector health and care strategy and plans, of which the NHS is part. Thirdly, this needs to be underpinned by changes to professional education—that is fundamental, but it has not yet been mentioned and I want to say something about it. Finally, implementation needs to be based around a shared vision that motivates and involves people, and efforts to build consensus and momentum.
I say in passing that I very much enjoyed the speech of the noble Baroness, Lady Blackwood. It was fantastically important. I also know that the noble Lord, Lord Bethell, and others will be talking about the links between health and prosperity. A healthy workforce and a prosperous country are fundamental.
The first major reform is the need to change the model, with much more focus on primary and community care, support for carers and social care, and action by many people. It cannot be just the same model or a question of more GPs and nurses. Around the country now, we see community health workers doing outreach, the great programme of Growing Health Together in Surrey, and people creating the future. We need to build on those examples of what a new model of primary and community-based care will be.
I turn to the second major reform. I have spoken many times in the House about the African saying, “Health is made at home; hospitals are for repairs”. I have also been pressing the case for quality standards to include healthy homes. The NHS is dealing with many problems that it has not caused, and those need to be addressed at source. There needs to be a government cross-sector health strategy and plan, of which NHS and social care is a part. I suggest that that plan needs to focus on the aim of creating a healthy and health-creating society—and indeed a prosperous society while we are at it. The focus should be not just on dealing with the problems—by tackling such things as air pollution—but on creating the conditions for people to be healthy. Think of Sure Start, for example, which I know many noble Lords will be aware of. Such a plan would create the conditions for people to be healthy. That is why we should be looking at health as being about healthcare and the prevention of disease but also the promotion of the causes of health and creating the conditions.
The third major reform underpinning all this is a need to transform professional education. I am happy to be associated with a radical group of young professionals who are starting to drive this agenda, recognising that they will need different skills for the sort of model I am talking about, as well as retaining the basic science.
The final point is implementation. My experience as chief executive is that I was lucky to arrive at a point when two things had happened. First, the Government of the day brought people together to create a plan; they built energy and hope, and there is not much energy and hope around today. That hope and energy created good will that carried us forward two or three years. That good will lasted a really long time and allowed us to make radical changes, including bringing in the private sector and other things. It is very much harder today, obviously. As was already mentioned by the noble Lord, Lord Hunt, by the end of 2005 waiting lists were below 1 million, with a six-month maximum wait, and there was more improvement to come from then on. It is very much harder today. The NHS is in worse condition, although there is still good care being provided, as the noble Lord, Lord Patel, emphasised. But the Government must do something—whether it is a new Government coming in or this Government continuing—to bring people together around this problem and create a solution that people will buy into.
We must also deal with the presenting problem. We cannot just deal with the long-term. A new Government coming in will have to look at the waiting lists and how to handle that, but they must then pivot to health. Twenty years ago, I believed that we must talk about the issues people were presenting with, such as waiting lists and A&E, and then pivot to a focus on health. We never quite pivoted to health. It is time now to change from talking about healthcare to talking about health, which embraces healthcare but also prevention and the creation of health.
Baroness Warwick of Undercliffe (Lab)
My Lords, it is a pleasure to follow the noble Lord, Lord Crisp, and I thank the noble Lord, Lord Patel, for providing the opportunity to consider this challenging but vital issue. I look forward to the maiden speech of my colleague, my noble friend Lady Ramsey of Wall Heath.
I shall focus my remarks on care needs, highlighting the crucial interdependence of care and the NHS. I will draw on my experience as a member of this House’s Select Committee on Adult Social Care, so ably and empathetically chaired by my noble friend Lady Andrews, whose report, A “Gloriously Ordinary Life”, was published at the end of 2022.
It is clear to me that, if we are to ensure the long-term ability of the NHS to deliver comprehensive healthcare for all, adult social care is crucial. Fundamental changes to social care funding and provision, in the form of a national long-term plan for adult social care, are a national imperative. We engage with the NHS at all points in our lives, but adult social care is often invisible and off the public agenda until we have a sudden need for it. Yet as our report noted, 10 million of us are affected by it at any one time, either because we receive care and support or because we provide paid or unpaid care. Because we are living longer and with more complex conditions, we are all increasingly likely to be one day included in that number.
Noble Lords will be aware that there is no national government budget for adult social care in England. Services are financed primarily through local authorities, bolstered by large numbers of people who fully or partly fund their own care. As the APPG on Adult Social Care highlights in its recent report Future of Care 5, this piecemeal approach means that social care is particularly vulnerable and will often be the first to lose out when—I say that advisedly—the NHS or local authorities have their budgets cut. The 29% cut in local government funding since 2010 has led to an estimated 12% drop in spending per person on adult social care services.
If we are looking at new models and systems of care and funding within the NHS, we have to change short-term emergency funding. Social care needs a long-term funding plan. As our Select Committee highlighted, improving adult social care should be seen not only as an investment in the NHS but in ourselves, as a resilient and caring society. As the quality and consistency of services has suffered, so has the pressure and demand on unpaid carers risen. Estimates suggest that there are more than 6 million unpaid carers in the UK, and the actual figure is likely to be much higher. Estimates of the value of unpaid care provided by family and friends vary between £100 billion and £132 billion a year. That is an extraordinary contribution to the health of this country and it really needs to be seen to be valued. However, as one carer who gave evidence to our report told us:
“Unpaid carers are often not even considered to be a part of the health sector and yet without them the sector would collapse”.
Despite their numbers, carers feel invisible and many are at financial, emotional and physical breaking point. Hearing the lived experiences of those who gave evidence to the Select Committee was sobering, at times even harrowing. Time and again, they told us of being unaware of what help was available, not knowing who to ask or how to access help, or of not being listened to and being put through tick-box exercises that bore no relation to their actual circumstances or needs. Time and again, these carers were falling between the gaps of a broken system, often over many years.
One parent carer told us that, while her daughter was under the age of 18, she had a central point of contact within the NHS, a paediatrician, who could project manage the different strands of specialism her daughter needed. Once she turned 18, all this fell off a cliff. The distinction made between a health need and a social care need means that unpaid carers, often family members, are on their own, battling to get information and help.
In the Select Committee report, we urged the Government to establish a commissioner for care and support who would be able to raise the profile of social care, act as a champion for older adults, disabled people and unpaid carers and accelerate a more accessible adult social care system. Sadly, this recommendation gained no traction with the Government, but, in light of the overwhelming body of evidence on the need to improve adult social care and advocate for those at the heart of adult social care of all ages, can the Minister give us any assurance that this will be revisited?
Lord Evans of Rainow (Con)
My Lords, I am most grateful to the noble Baroness for finishing just before five minutes were up, but she has been the only one. The excellent speech of the noble Lord, Lord Patel, finished two minutes before his allotted time. I gently remind all noble Lords to keep to their allotted time of five minutes. I know that the next speaker will keep to it because he is a perfect timekeeper.
Lord Bethell (Con)
My Lords, it is a great privilege to speak after the noble Baroness, Lady Warwick. I thank my good friend, the noble Lord, Lord Patel, for bringing about this important debate. I declare my interests as a research fellow on public health at the Milken Institute School of Public Health and a research fellow on biodefence at King’s College London, and as chairman of Business for Health, a community interest company which advocates for greater involvement in health by businesses.
There have been so many powerful words about the importance of investing in our healthcare system. I saw at first hand the incredible power of our national health system during the pandemic. I love the system and what it does for our society. However, we cannot duck two particularly important problems when debating this key issue.
One is the unbelievably heavy cost to society of our healthcare system. The deputy chair of the NHS, Wol Kolade, whom many will know, put this very bluntly; when he joined the board it was £100 billion a year, and it is now edging towards £200 billion a year. He asks:
“Where the hell is it going to stop?”
That is a pertinent question for this debate. We cannot treat our way into good health. We have to look at the underlying health of the country and at how we prevent disease.
We also have to think about the return on investment of our healthcare system. If we want to sustain it and to have it in a secure financial position, we have to ask whether it is giving a return on investment. We have 2.8 million people who are long-term ill at the moment and half a million extra who have left active employment. The OBR predicts that there is no hope that they will return, and there may well be another half a million on the way out in the next year or so. If the economic and spiritual prosperity of the country is not being underpinned by our healthcare system, we have to wonder whether, as a number of noble Lords have pointed out, we need a bit of a rethink.
That is why, alongside the noble Lord, Lord Filkin, and other colleagues, I launched Health is Wealth: A Fast Start for a Covenant for Health. We prioritised five areas of prevention which I believe are achievable and affordable and will yield a massive economic benefit. First, we have to scale up and deliver on our ability to detect and address the risk factors of disease. I am grateful to my noble friend Lady Blackwood for her words on genomics. Secondly, we have to strive for a smoke-free Britain. We should all celebrate this week’s achievement on the smoke-free generation legislation, but there is so much more we can do in the next 10 years to reduce the 5 million people who already smoke. Thirdly, we need to build a much stronger focus on healthy eating, making it affordable for all and helping us reverse the upward trend in obesity. Fourthly, we must focus on the health of our children, ensuring that healthy habits are ingrained from an early age. I emphasise mental health here, in particular the role of the digital world in provoking a mental health challenge for our young people. Finally, we need to ensure that no area is left behind and look at helping those who live in areas with the worst health to live longer. That includes the underlying environment in which they live—the dirty air, the mouldy homes and online and toxic workplaces.
The moral argument for this prevention and upstream focus is very strong, but the economic argument is overwhelming. We cannot keep pouring increasing amounts of money into more hospitals, doctors, nurses and medicines in the hope that we can treat our way out of this problem. We have to address the determinants of health. Can the Minister say what more can be done in this space from a position of ambition for the NHS? We cannot keep scapegoating the NHS for the poor health of our country. We have to look upstream and focus on the determinants of health.
Lord Kakkar (CB)
My Lords, it is a great pleasure to follow the noble Lord, Lord Bethell, and to congratulate my noble friend Lord Patel on the thoughtful way in which he introduced this important debate. I declare my interests in the register, in particular as chairman of the King’s Fund and as chairman of King’s Health Partners.
My noble friend alluded to the report of your Lordships’ ad hoc Committee on the Long-term Sustainability of the NHS, published in April 2017, to which the Government responded in February 2018. The debate to which he referred extensively covered the questions raised in that report and the Government’s response, but, regrettably, very little has changed since. It must be recognised that we have had the global pandemic, an acute health emergency, and many other challenges, but the reality is that we have not been able to address in any meaningful measure either acute or mid-term challenges in the sustained delivery of health and care in our country, and nor have we even initiated a meaningful approach to its long-term sustainability.
We have heard in this important debate that performance, regrettably, is not where it should be in clinical outcomes. It is well recognised and sought after by all parties in all constituencies that we improve clinical outcomes. They are not as good as modern medicine would predict and could deliver. Operational delivery is poor and its trajectory in the NHS does not appear to be improving. On workforce, we have found it impossible to inspire and motivate healthcare professionals, be they clinicians, nurses or other healthcare professionals, to remain committed to the NHS and be inspired not only to serve but to innovate, undertake research and ensure that the application of that research and innovation is quickly brought to bear for the benefit of patients. More broadly, the research and innovation agenda, which our country has led for so many decades, appears to be falling behind. If that agenda is not at the centre, sustainable healthcare in our country will not be achieved.
That is not to say that there have not been many important and very well-meaning initiatives over decades to address acute problems and longer-term sustainability issues, but they have not delivered. As a result, we must ask how we are going to reach a position where we can develop a national consensus that brings together diverse political, public and professional constituencies with a common understanding and vision for the future—a consensus that is appropriately motivated and understands that what is proposed is deliverable and remains a deep-seated national commitment across the political divide?
Part of the problem may be that questions, with regard to the medium-term or long-term sustainability of health and care in our country, are projected and considered through the lens of a clinical, a delivery or an innovation problem, rather than looking more holistically at all those issues. Some of them were addressed in the previous NHS long-term plan, but they need to be considered more broadly in the context of our country’s economy and other policies, such as immigration, which need to be co-ordinated with a wider understanding of healthcare delivery needs, if we are to have a sustainable long-term plan.
I follow the fine example of my noble friend Lord Patel and ask the Minister, as well as the noble Baroness, Lady Merron, and the Liberal Benches, what approach are they going to take, for the national interest, to achieve consensus on the needs for delivering our country’s health and care? How will this consensus be delivered? In the debate on the noble Lords’ report in 2018, the idea of a royal commission was dismissed as something that was not politically acceptable and would not deliver in a short enough timeframe. Six years have passed since that debate; maybe something like a commission would have delivered the answer in that period. It is now essential that we develop a clear consensus and have the courage to adopt a long-term plan that addresses the holistic needs beyond the question of clinical care alone.
Baroness Ramsey of Wall Heath (Lab) (Maiden Speech)
My Lords, thank you for the opportunity to give my maiden speech. I start by thanking the noble Lord, Lord Patel, for the opportunity to speak in this important debate as well as noble Lords on all sides of the House, who have made me feel so warmly welcome. I thank Black Rod—who actually knows where Wall Heath is, without any explanation—her staff, the doorkeepers and many others who have been so supportive and informative, helping me on a daily basis to find my way around this beautiful building.
I am also grateful to my friend, the noble Baroness, Lady Hayman, and my noble and learned friend Lord Falconer for introducing me, and to my noble friend Lady Pitkeathley, who insisted that my ninth day in this House was the right time for me to give my maiden speech.
When I got the news that I was to be nominated for a peerage, my first words were unrepeatable for Hansard. My second were to regret that my father and mother are no longer alive to witness this amazing honour and privilege. They were Lancastrians, children of men who worked down the pit, from a long line of proud trade unionists and co-op members. My mother wished all her life that she had had the opportunity to gain educational qualifications, but she had to leave school at 14, and then worked to pay the doctors’ bills, because her own mother was dying of stomach cancer, just before the introduction of the NHS.
My life-long personal interest in the NHS was originally driven by the life experiences of my older sister Patricia, who died six years ago. Patricia was born in the 1950s, with what we now call learning or intellectual disabilities, but at the time she was labelled first as “mentally defective”, then “mentally handicapped”, and she was also physically disabled. She lived from childhood until the 1980s in a huge, forbidding mental hospital in the West Midlands, which I was scared to visit as a little girl and teenager. As the years went on and the NHS evolved, she moved into the community, into a house with others, and we could visit her without having to ask for permission, and become involved in her medical and personal care. I became her co-guardian after our father’s death.
I have inherited my mother’s life-long gratitude to all those who work for the NHS, not least those in the hospital opposite this place—St Thomas’—where two of my children were born and three have been patients, one with a life-threatening peanut allergy, another with severe childhood asthma. Over time, my personal commitment to the NHS broadened into the professional. I was appointed chair of Lambeth Primary Care Trust, just over the river, and relished the opportunity to work in partnership with GPs and others to try and make a real difference to local people’s lives by, for example, helping to reduce teenage pregnancy and smoking rates. I then joined the board and became vice-chair of UCLH, where my youngest child was born.
In 2016, I was honoured to be appointed the chair of Cambridge University Hospitals, otherwise known as Addenbrooke’s. There, I was privileged to work with some of the world’s most distinguished doctors and biomedical scientists, whose commitment to ground-breaking research was matched only by their determination to see the results implemented to the benefit of the public at large—truly, medical research “from bench to bedside”.
Whatever comes next for the NHS, it is clear that, when it is properly funded—as the noble Lord, Lord Stevens of Birmingham, fought hard for in challenging economic circumstances—its people do wonderful work. This is particularly true when doctors, nurses and other health professionals, both in and out of hospitals, as well as those in public health, work truly collaboratively to help our growing and older population stay in good health for as long as possible.
In my experience, structural reorganisations designed—however well-meaningly—to try to achieve improvements are trumped every time by positive relationships between clinicians, managers, patients and the public, supported by the right level of funding in the right place, at the right time. This is just as true for the NHS’s engagement with other public services. We are all kept as healthy as possible, and taxpayers’ money is spent well, when the NHS, local government, housing associations and schools work in partnership to support adults and young people with chronic and challenging conditions.
The NHS’s continuous commitment to finding new methods of care, in partnership with others, improved my sister’s life immeasurably over the years. Free healthcare, available to all who need it, at the point of delivery, seemed to my mother like the best thing that a Government could offer its citizens, as she paid those bills long after her mother died. She was right, and said so repeatedly when, 40 years later, my father was being treated for lung cancer. The NHS care that he was able to get at home, from GPs and district nurses, was literally unaffordable for my poor grandmother.
I am grateful to have been able to contribute to this important debate, as well as to hear and learn from so many distinguished noble Lords. I look forward to many more excellent, informed and expert debates in this House—listening carefully to everybody—which this House is famous for.
Baroness Pitkeathley (Lab)
My Lords, it is an honour and pleasure to follow my noble friend Lady Ramsey, and to be the first to congratulate her on her truly memorable maiden speech. I should not be surprised that she has made a remarkable speech, because she is a remarkable person who brings a wealth of experience and achievement in public service to your Lordships’ House. As a barrister working in local authorities, as chair and non-exec on many health agencies and as an upholder of standards in public life, she has already achieved a great deal. Indeed, the range and breadth of her experience is so great that she could have made her first contribution in a variety of debates. I am sure your Lordships will be glad that she chose this one. As we have heard, she brings willingness, commitment and enthusiasm to continuing her work in this latest phase of her public service. Her colleagues on these Benches, and throughout your Lordships’ House, will be grateful for her presence, and look forward to many more memorable contributions.
I thank the noble Lord, Lord Patel, for this debate and for his indefatigable pursuit of improvements in health and social care. Like many noble colleagues, I could give examples of where great care is happening, and my own recent experience could not be improved. The use of technology to make appointments and to deliver care was fantastic, as was the skill and understanding of all the professionals with whom I came into contact. However, too often patients report very differently. As we know, 24% satisfaction with the NHS is nothing to be proud of.
I have lost count of the number of health debates in which I have taken part in my 27 years in your Lordships’ House, and in every one there has been agreement about what is needed to provide the comprehensive and timely care that we seek. We always agree on two things—first, that we need more preventive services, as the noble Lord, Lord Patel, and others have reminded us. We treat people too late and allow their conditions to become chronic, so that major interventions are needed when small ones would have sufficed. We do not treat the broader picture: we do not look at the lifestyle issues and diets that cause the conditions or the poverty that is the reason why people eat the wrong food, which in turn causes diabetes, the need for new joints and the disabilities that mean people cannot work or have a tolerable, pain-free life. Still less do we think of surveying living conditions, such as putting in a handrail and getting rid of the rugs that cause falls, which in turn create huge amounts of work for the NHS and distress for an older individual.
The second area on which we have always agreed is that we need more integration. I shall have more to say to your Lordships’ House next month, when the report of my Integration of Primary and Community Care Committee is debated, but, for now, I agree with other noble Lords that the NHS allocates an excessive amount of funding to reactive hospital care at the expense of preventive primary and community care. This was not just the conclusion of my committee but the strong opinion expressed by all former Health Ministers and Secretaries of State who gave evidence to it. They were from different parties and Ministers in different circumstances, but they were all adamant on this point, as many noble Lords will be in today’s debate.
The mismatch in the levels of funding and importance that is so clear in the NHS is even more significant when it comes to social care. We are all victims of the historical accident that means that local authorities fund social care. Nobody knew that we would live so long and have so much need for support in 1948, but we have made only pathetic or failed attempts to rectify that situation. I know that the Minister would not call the better care fund either “pathetic” or “failed”, but it is, at best, a sticking plaster to cover the basic flaw in our funding system.
Unless we get better integration between health and social care, we will never deliver comprehensive care, and the divide will continue. To overcome that divide, we have to address the join between the NHS and local authorities and areas where professional silos and the arrogance that goes with such divides have not been eradicated. We never seem to have found the ability to translate local success into national guidelines. The “not invented here” syndrome stymies all attempts at change.
Do not get me started on the main providers of both health and social care. I am grateful to the noble Baroness, Lady Warwick, for mentioning unpaid carers. It is not the NHS or local authorities but family carers who provide, willingly and with love, billions of pounds of care—estimates vary, but it is well over £150 billion, or the cost of a second NHS. Does it not make sound economics, as well as moral good sense, to support them better than we have ever succeeded in doing? They are the best-value service any nation could want. Yet what do we hear? We hear of carers being persecuted, even prosecuted, for invertedly going £1 over the earnings limit on the derisory amount of the carer’s allowance. We hear of carers being forced to abandon paid employment, building up future poverty for themselves and future liabilities for the state. We hear of carers being ignored, having their skills knowledge and experience dismissed and not being consulted, with their own health needs going unrecognised. Carers are, and will continue to be, the bedrock of health and care services, and I hope that the Minister will confirm the importance of recognising that.
Baroness Finlay of Llandaff (CB)
My Lords, I declare my interests as an NHS consultant and chair of the Bevan Commission. I congratulate the noble Baroness, Lady Ramsey of Wall Heath, on her very moving speech and on reminding us of the hardship of the pre-NHS days and why the NHS is so important to us. The contribution of the noble Lord, Lord Patel, in opening this important debate was characteristic of his great speeches.
I had the pleasure of being a member of the Times Health Commission, where we were given the task of suggesting reforms to improve the NHS. It was a very interesting experience, taking evidence from a wide range of people, including previous Ministers. At the end of our deliberations, we came up with a 10-point plan for health, which I will briefly outline now. For patients, it is clear that digital health accounts, such as patient passports accessed through the NHS app, are crucial for the future. Patients need to be able to co-ordinate their appointments, manage any medication and view their own records in full. We cannot expect people to take control of their own health if they do not have their test results, referral letters and vaccination and intervention records, or the ability to review, in their own time, the outcome from different consultations. Patients retain a small percentage of what they are told in a consultation, so it is very important that people can review things in their own time and with their families.
In Wales, we established Talk CPR to address the very important conversations around end of life and resuscitation procedures, which establish whether somebody wants ongoing treatment and intervention. We found that, by giving patients video books to take home, they were much more comfortable discussing issues than trying to have all that discussion in the context of a short consultation. In the Times Health Commission, we focused on the workforce—including the need to reform the GP contract and to write off student loans for people who continue to work in the NHS rather than leaving it—and the importance of no-blame compensation approach to errors, rather than the current blame culture that demoralises.
We addressed the need for mental health support and tackling obesity in particular. It is a precursor to so much disease, and the antecedents of illness can be decades before a patient presents. The importance of research and investing in it became more and more evident. Data collection is crucial for us to monitor and understand better the course of health in our own country, but also as a basis for inward investment from pharmaceutical and technological innovators. The NHS could be a major test bed, with integrated information and fast-track processes, to attract and retain researchers from around the world with inward investment, but unless we speed up the processes for investment we will never reach our goals.
One of our recommendations was to have a healthy lives committee to look at the impact of improved public health and a healthy life expectancy, addressing the antecedents of poor health. But whatever we do, bad things happen: people have accidents, severe illness hits out the blue and new infections emerge. Although palliative care is now in legislation as a core service, contracting is not the same as ensuring that patients have access, yet it is cost effective to involve palliative care services early. We need a national funding formula to support integrated care boards in establishing contracts with palliative care providers. Services must be rapidly responsive seven days a week; without that, the sad toll of inappropriate transfers to emergency departments out of hours will not decrease.
In recovery from a serious accident or devastating illness, early rehabilitation becomes crucial to improve outcomes and decrease costs. Next Monday, I am hosting a drop-in on rehabilitation with the full range of professionals involved. Rehabilitation is cost effective for the NHS, yet, like palliative care and hospice services, it is very patchy in provision. As such, we allow distress and ongoing, avoidable morbidity to accumulate and jeopardise long-term outcomes, in both the patient and the bereaved. Fair access to help in response to need is essential; we must never forget the patient.
Baroness Chisholm of Owlpen (Non-Afl)
I congratulate the noble Baroness, Lady Ramsey, on a very moving and brilliant speech. I also thank my noble friend Lord Patel for bringing this timely debate to us today. As he mentioned, community will play a vital role in the future sustainability of the NHS. I will speak briefly on community nurses, who deliver, along with the help of care assistants and families, bespoke care to individuals in their homes and the community. It is not unusual for these professionals to live in the area where they carry out their work, leading to—I feel this is a key point—them having the added advantage of often being aware of the families’ circumstances, bringing the continuation of information, relationships and management. They foster an organic connection for patients and their families—care that is delivered to the community from birth to death.
We all know that primary prevention avoids the manifestation of disease, improving health through information and lifestyle behaviour, which includes dietary and nutrition interventions along with vaccinations, strategies to promote sexual reproductive health, family planning and mental health well-being. If this healthcare can be provided in the community in family hubs, schools, the workplace, medical centres and homes, it obviously frees up hospital beds and unnecessary GP appointments.
However, from what I have read, 4,000 district nurses are providing care for a population of around 55.8 million. That is one nurse per 14,000 people, whereas there is one GP per 1,600 people. The fall since 2010 equates to almost half of NHS community matrons and district nurses, and 29% of health visitors. Health equality is achieved when everyone has a fair and just opportunity to be as healthy as possible. Community-based nurses are well positioned to play an important role in addressing the underlying causes of poor health.
We are all well aware that it is vital that we move from concentrating solely on treatment and management of disease to prevention and social needs. Embedded within the community, community professionals are well positioned to build trust. They see first-hand the limitations associated with those they are involved with, be it in housing, family, mobility, transportation or dietary issues, to mention just a few. They connect and engage with partners from across social, health and other services. That is the ideal, but without the professional numbers required to carry out this vital work and giving them time with their clients, along with time to report back to the multidisciplinary team, none of the above can be achieved.
It is an attractive career that provides flexible working and a diversity of roles as an autonomous and independent practitioner. With the use of modern technology, there should be more productive time with clients and less paperwork. But a survey done by The Queen’s Nursing Institute in 2022 found that, in practice, the application of digital technology is poor. The survey pointed out that poor user experience appeared to be around design and function rather than a lack of computer literacy or enthusiasm. It went on to highlight problems with unsuitable hardware and software, lack of integration and repetition of data entry, as well as a lack of compatibility between different computer systems. That is disappointing. Can the Minister tell us what has been done in this regard and what is being done to raise the level of community nurses and encourage nurses to go into this genre of nursing?
In conclusion, over the past few weeks we have had a record fallout of the workforce due to long-term illness. Community nursing enables patients to remain independent in their homes with bespoke care, which is obviously beneficial to their health, economically beneficial to the NHS and beneficial to the productivity of the country. I have rather rattled through this, but as with sustainability of the NHS, time is of the essence, and it is the same in this Chamber.
Lord Warner (CB)
My Lords, I congratulate the noble Baroness, Lady Ramsey, on her excellent initial contribution to our debates. Unlike the noble Lord, Lord Patel, my experience is that too many interests are still worshipping at a 75 year-old NHS shrine that only 25% of the population is satisfied with. The NHS is trapped in an over-centralised management and service delivery model that cannot improve efficiency fast enough to cope with the tighter funding it faces.
As others have said, too many services are delivered to what I would describe as overcrowded, expensive and overprotected acute hospitals. We have neglected investment in primary care, community health services, social care and public health. We should ignore pleas to pour more money into this dysfunctional 75 year-old and focus on fundamental reform, led by people capable of delivering change at pace. My sketch of a five to 10-year operational plan to do this has five main strands.
First, we need fundamental change of a failing top management at the Department of Health and Social Care and its replacement with a new health and care management board, chaired by the Health Secretary, a CEO with high-level management experience outside the NHS, supported by a chief people officer for all workforce issues, and a chief finance and efficiency officer. I will not go into more detail, but I think this would lead to the abolition of NHS England—which would get quite a few cheers in the NHS, I suspect— and some other health quangos, which would get a further lot of cheers.
Secondly, we should consider emulating Singapore, which has similar health outcomes to the UK while spending less than 5% of its GDP on health. This low figure is accomplished because it delivers so many services outside acute hospitals, using up-to-date technology. It is very difficult to get into an acute hospital in Singapore. To achieve this change, we need to restrict the proportion of NHS funding going to acute hospitals over a five to 10-year period and invest much more in community-based services. We would need a clinically led national team, perhaps using the Academy of Medical Royal Colleges, to concentrate more specialist services in fewer sites, but with an enhanced capital investment programme for selected hospitals. Those hospitals with fewer services should become local community hospitals, and this should be the end of the district general hospital, a 1960s model. To make these changes stick, they should be underpinned by secondary legislation.
Thirdly, in consultation with the Royal College of Surgeons, all elective surgery should be undertaken in its own units, either provided by the NHS or contracted for with the private sector at NHS prices, which we managed to achieve in the noughties. Again, that would be a capped five-year budget which would not be used for other purposes.
Fourthly, we should be devolving responsibility for the management of all GP contracts, primary care, community health, social care and public health to new regional bodies, with elected mayors heading up as many bodies as possible, using devolution deals such as that done in Manchester. There should be a protected budget for this sector, growing faster than acute hospital budgets, with any real-terms cuts reported to the Public Accounts Committee.
Fifthly, a statutory proportion of the NHS budget should be devoted to public health, administered under the guidance of a new independent office of public health, set up on the lines of the Office for Budget Responsibility. It would be able to take the kind of difficult decisions on public health that the experience of recent years suggests elected politicians find very difficult. I would call this the “tough love approach”, and it is the direction of travel the NHS needs to consider taking. If the Front Benches want to find out more, they can go to the Social Market Foundation website and read my pamphlet on the NHS at 75.
Lord Reid of Cardowan (Lab)
My Lords, I congratulate my noble friend Lady Ramsey and I thank the noble Lord, Lord Patel, not only for securing the debate but for his sweeping overview of the coming years. I have a much more modest aim. I would like to tackle just one issue: the 7.5 million people who are on the waiting list, suffering sometimes pain and very often distress. I will look at the reforms to the NHS in the years 2000-05 and how they were tackled. There are a number of former Ministers in the House, and they will be well aware that think tanks rarely look back with kindness and positivity at our efforts. I was therefore somewhat surprised and pleased that the King’s Fund report of 2022, Strategies to Reduce Waiting Times, was unusually positive. Indeed, it argues that some of the NHS reforms I was involved in, along with the noble Lords, Lord Crisp and Lord Warner, actually worked. That was a first, I think, for a think tank’s review of ministerial activity.
The report starts with the overall judgment that:
“The years following the NHS Plan in 2000 provide important lessons for tackling long waits … successfully”.
I suggest, therefore, that we might look at some of the levers that we used, because we have so many people waiting in pain and distress at the moment, as I said. The simple judgment of that report is important, because it means that we do not need to be fatalistic about the large number of people waiting in care. We faced the issue before, and as a nation we succeeded in solving it, so let us briefly mention the reform levers that the Government might want to consider or to enhance.
From 2002 we developed the policy of paying NHS trusts more money if they carried out more work. Put like that, it sounds very simple, but at the time it was portrayed as an extremely controversial, right-wing point of view. Ironically, that came from some of the people who naturally assumed that if they produced more at work, they would get paid more, but they felt somehow that it was wrong for NHS entities to work on that basis. They argued at the time that it would undermine the NHS. It did not. It acted as a clear incentive to do more work, and because more work got carried out, waiting lists, among other things, began to fall.
Secondly, we realised that there was no point in providing an incentive to a trust to obtain more resource by carrying out more work if at the year end the trust had to give back any surplus to the centre. That is why in 2004 we created foundation trusts, which could roll forward the resources they made and reinvest them. Again, arguing for this caused many to attack the Government at the time for being too right-wing.
Thirdly, from 2002 we started to offer patient choice to those who had been waiting for more than six months. I was told at the time, as was my predecessor Alan Milburn, that this was no use because patients did not have the knowledge, the ability or the capacity to exercise that choice. Funnily enough, of course, that too was proved wrong because, rather than wait longer, most patients chose to go somewhere other than their local hospital, despite the disadvantages of travel, because they valued the shorter time before treatment.
Fourthly, the money followed that patient choice, putting patients, not providers of healthcare, in the driving seat and rewarding those carers who best met patients’ needs and satisfactions.
Fifthly, we not only used the private sector to provide services for NHS patients but created, through the independent sector treatment centres, a new form of private sector that increased productivity by each concentrating on one form of treatment.
Taken together, those were the reforms that effectively reduced massively the waiting lists. Of course, there were extra resources. The only criticism I would make of the noble Lord, Lord Patel, is that he referred to Tony Blair’s promise of a 6% increase per annum as uncosted. It was not uncosted. We costed it—we just had not told the Chancellor. That was the controversy. As I said, with each reform there was great political controversy.
My final point is that thereafter there is a mystery, because you would assume that after the Labour Government left office, the Conservative Governments that came in consecutively would not only adopt those practices but turbocharge them. In fact they dropped them and the practices disappeared, apparently disintegrating, until last year. I pay credit to the Minister who is replying today, because he was one of those who pushed for their readoption. The lessons of those five things are very important for any future Government, and I hope they will be taken on board by a future Labour Government.
Baroness Murphy (CB)
My Lords, like the noble Baroness, Lady Pitkeathley, this morning I was reminiscing about the number of NHS debates I have taken part in since I came here 20 years ago. It is at least one a year—I gave up counting when I got to 20—and the tenor of those debates has got more and more depressing. We have had words of wisdom that I have heard several times before—I mention in particular the noble Lord, Lord Hunt of Kings Heath, who always gives a characteristic, brilliant overview of what needs to be done. I disagree with him and the noble Lord, Lord Reid, about the Blair years’ injection of money and reforms. They certainly improved things for a short while but they were never continued, neither during the Blair years themselves nor afterwards. One of the problems with central government control, which we have had, is that you have no history. Nobody remembers. The next Department of Health enthusiasms come along, and no history is remembered by one set of Ministers after another.
I find it utterly heartbreaking to witness what has happened over the last 20 to 30 years, having been first employed in the NHS when I was 17 as a healthcare assistant, having been through the whole gamut of levels of interest and having worked alongside the NHS. No amount of money thrown at the NHS will do anything to improve productivity, generate a workforce proud to belong to the NHS, or produce a quality of care to rival the best in the world that we aspire to, nor change the chronic defensive culture, which is disastrous. We have the skills and the talented people, and we waste them by profoundly inefficient human and capital infrastructure.
The NHS is dying. Dentistry has died in the NHS, more or less, and the NHS is also dying, bit by bit. I was shocked when I was admitted as an emergency last year to a district general hospital in East Anglia. The quality of care and the ongoing support provided were appalling, and that is not a badly rated hospital. I understand that now up to a quarter of young people in London aged 19 to 24 cannot bear to be treated as they are by trying to get a GP appointment, so they go online and pay £39 for an online GP appointment. They are seen on video instantly and they get a prescription the same day. That will happen more and more unless we do something.
Of course, the last 13 years of organisational muddle, with no one able to make any serious decisions and endless time-wasting, has made things a lot worse. We still have this centralised system, which has not changed since 1948 and which gets worse from time to time.
In March there was a Question—I think the noble Lord, Lord Markham, answered it—about the decision to concentrate children’s cancer services at the Evelina rather than the Royal Marsden. I have no axe to grind—I do not know either of those institutions—but my overwhelming sense was that the noble Lord, Lord Markham, should not have called that in for another decision or looked at it again. He should have said, “Let the NHS managers who have made this decision get on with it”. The sooner we get our hospital providers out from under central control, the better. The model where we have everybody in the provider system and everybody in the funding system controlled by central government works only in very small countries. Luxembourg and Iceland both have our system, and it works quite well. After many years of having a more sensible system, the Canadians adopted our system and their health service has gone steadily downhill, with increased waiting lists and people not getting the central funding from federal government that they need. It does not work. When will we accept that we need to develop a model where the providers and purchasers are separate?
I have run out of time so I will just end with my hope that the next Government, whatever colour they are, will get to grips with the need for profound reform, and of course include social care as well in the necessary reform.
Baroness Tyler of Enfield (LD)
My Lords, I, too, thank the noble Lord, Lord Patel, for the debate and I congratulate the noble Baroness, Lady Ramsey, on her outstanding and moving maiden speech. As we have already heard today, public satisfaction with the NHS has fallen to an all-time low but, despite this, there is still strong support for its three founding principles: free at the point of delivery, primarily funded through taxation and available to everyone.
Last year, the King’s Fund published a report on the performance of the NHS compared with the health systems of 17 other OECD countries. Essentially, it was a scorecard which showed that, on the plus side, the NHS performs well in protecting people from some of the “catastrophic costs” of falling ill, and a relatively low share of the UK’s health budget is spent on administration—some might be surprised at that. On the minus side, the report concluded that the NHS has fewer key resources than its peers, below-average health spending per person, fewer doctors and nurses, less equipment such as CT and MRI scanners, and fewer hospital beds. In addition, the report said the NHS performs noticeably less well on outcomes such as survivable cancers, treatable mortality and life expectancy.
Various independent commentators have concluded that changing the funding model is not the primary answer. Nor, of course, is it either desirable or feasible to always just pour more money in. The important thing, as the Health Foundation has argued, and I concur, is to get the current NHS model to work better—that is, to reform the way it works. The key, surely, is to increase capacity in the right places. That is so simple to say but so hard to do. It is indisputable that funding growth is skewed towards the acute sector. Despite the majority of daily NHS activity happening in general practice and the community, a large proportion of expenditure on health and social care goes towards acute hospital trusts.
In my view, the answer to overcrowded hospitals is not simply more hospitals. As the noble Lord, Lord Patel, and others have said, the health and care system must be radically refocused to put primary and community care at its core if it is to be effective and sustainable and so that people can get access to their GP, a pharmacist and a district or mental health nurse.
That was one of the key findings of the Select Committee on Integration of Primary and Community Care, on which I had the privilege to sit, which was so expertly chaired by the noble Baroness, Lady Pitkeathley. The committee found a lack of co-ordination between the everyday primary and community services relied on by people using the NHS, which was leading to substandard care, missed opportunities for home or community-based treatments and overstretched hospitals being put under even further strain.
I turn now to productivity. Respected health commentators have been looking at what is called the productivity conundrum. A recent Institute for Government report found that, despite increased spending, much of which has gone on increasing staff numbers, there has been no resultant rise in productivity, if measured against metrics such as the number of patients treated. We really need to understand why this is. The report drew particular attention to the fact that most hospitals are running at above full capacity. They do not have enough beds and it is estimated that each day around 13,000 beds are occupied by people who do not need to be there but cannot be discharged because of lack of community and social care. We all know that, after years of neglect and underfunding, our social care system is in crisis.
Secondly, despite notable increases in the headline number of staff, the NHS is losing too many experienced employees and they are being replaced with junior staff who are naturally less experienced and need more support. Staff burnout, low morale and pay concerns are cited as the principal reasons for this. A recent IFS report also concluded that, while
“It is difficult to measure productivity … the NHS is less productive now than pre-pandemic”,
particularly in hospitals. The report was at pains to say that was not about staff not working hard but pointed the finger at Victorian estates, too few diagnostic machines and outdated IT systems causing communications problems within and between hospitals.
I believe that there should be far greater focus on retention and making the NHS an attractive place to work. That should be central to the NHS workforce plan, and we need a plan for social care, too. If not, we shall never clear the backlog or reduce waiting lists. We also know that valuable NHS equipment and operating theatres too often stand idle in the evenings and at weekends. Can the Minister say what plans the Government have to address this and whether they might include bringing in independent clinical teams from outside the NHS—a point raised by the noble Lord, Lord Reid.
Finally, are we going to see a productivity plan to set out how the productivity increases announced in the spring Budget, alongside the £3.4 billion additional capital investment will be achieved? In my view, Parliament needs to be scrutinising these plans.
The Lord Bishop of Newcastle
My Lords, I thank the noble Lord, Lord Patel, for securing this debate. It is a pleasure to follow my friend, the noble Baroness, Lady Tyler, and I commend the noble Baroness, Lady Ramsey, on her excellent maiden speech. I welcome this debate’s focus on health and social care and in this regard I pay tribute to the noble Baroness, Lady Warwick, for her speech. Too often, social care is considered in public debates primarily in the context of ensuring that the NHS is not overwhelmed.
This debate’s title is rightly ambitious about social care reform. But given the current state, social care simply needs to be there when people need it, in a comprehensive, timely and affordable way. This was highlighted by the case in Newcastle of Dr Jo Wilson, who had been diagnosed with dementia in 2020. Following her death in January 2023, her husband Bill, who had provided round-the-clock care as a result of inadequate and inconsistent care support, described the care system as “broken”. Many cases, such as those raised by campaigns such as John’s Campaign, founded 10 years ago, are also linked to poor dementia care, particularly access for loved ones to those under care.
The Archbishops’ Commission on Reimagining Care developed a vision for social care, drawing on Christian theology and values. The commission heard the need for a fundamental shift in how social care is thought about, organised and delivered. It proposed a national care covenant, a process initiated by government in dialogue with stakeholders to clarify the responsibilities of everyone: individuals, families and communities, alongside local and national government. What assessment does the Minister make of a covenant as a means of rebalancing social care roles and responsibilities?
Areas prioritised by the Government in recent years are worthy of attention. We need more digitisation of systems and databases. We certainly need more care workers, and an attitude shift around that work’s importance, reflected in pay and conditions, as other noble Lords have mentioned. Indeed, the greatest challenge the sector faces in delivering high-quality care and support nationally is workforce recruitment and retention. The north-east is no exception: in 2022-23, the vacancy rate was 8.7%, with 6,400 vacant posts.
I commend the newly published report by the think-tank Theos, which considers the intersection between love, work and care and offers a different and profoundly helpful lens for valuing care more highly. It says:
“Love is a skill, and … is what makes care possible”.
The lack of a shared sense of why social care matters may contribute to attempts at reform being abandoned. With the health and social care levy scrapped and the cap on costs delayed, there lacks a long-term strategy around funding social care. I worry that neither this debate nor the fundamental debate about the value and purpose of social care are taking place. It can feel as though there is a collective burying of heads and a desire to avoid the next NHS crisis rather than recognising that the success of our health and care systems are fundamentally bound up with one another. Where is the vision? Social care demands our focus, not as an end in itself but as the very means by which we begin to experience life in all its fullness.
Lord Turnberg (Lab)
My Lords, I too thank the noble Lord, Lord Patel, for his very wise words when introducing this debate; I would expect nothing less. What a pleasure it was to hear the maiden speech of the noble Baroness, Lady Ramsey; I am sure we will hear more from her.
The excellent Library report for this debate suggests that there may be little benefit in seeking new ways of funding and new systems of delivering the NHS. I was reminded of the economist Maynard Keynes, who said that any proposed change should not only produce improvement but be sufficiently better to make up for the evils of transition. We have seen plenty of evils of transition over the years. I will focus on one set of problems among the many which need attention.
The difficulties faced by patients coming to hospitals have been well rehearsed: crowded emergency departments, queues of ambulances waiting outside, long waiting lists for patients needing to be admitted, cancelled operations—the list is endless. I am acutely aware of them as someone who has spent most of his working life in hospitals. However, if there are to be any solutions, they must be found outside hospitals and in the community, where social, community and primary care are hardly coping under their loads.
This is where the problems for hospitals, and for everywhere else, arise. Age UK noted that 700,000 elderly patients were attending emergency departments because they could not get an appointment to see their GP. Over 15% of acute hospital beds are occupied by patients waiting, sometimes weeks, to get out of hospital. Some patients wait so long for care in the community that they are much more ill by the time they reach hospital. It is therefore little wonder that hospitals are overwhelmed. So, I make no excuse for focusing on the problems in the community, as other noble Lords have. They have been accumulating for many years. Local authorities’ funding has been squeezed to the point where they clearly are not coping. Because almost two-thirds of their budget is spent on social and community care, these are being cut to the bone.
We now have far too many vacancies for health visitors and district nursing posts. Meals on wheels has disappeared and support services are squeezed out completely. Yet demand for social care is increasing. There were almost 2 million requests to social care departments in 2023, and waiting lists are growing. Some wait many months for assessments and when they get to the front of the queue, they have to go through a tortuous and bureaucratic process that few can understand. As others have said, it is a two-stage system: an assessment of whether they really need support, and of whether they can afford to pay. Few can understand it, and few can pass.
Then, there is the problem faced by the very large number of people cared for at home by relatives and friends. Many such carers give up paid employment to look after their relatives. If they apply for help and if they can get through the mountain of bureaucracy, they may be able to receive £76.75 per week—ludicrously low recompense when it is recognised that this huge number of independent carers, several million of them, are saving the Exchequer vast amounts of money. Surely, we can do better than that.
Finally, I will shine a light on what is a disgrace in social care: the way we treat our social care staff. We treat all NHS staff badly, but care staff are at the bottom of the pile. Not only are they the poorest paid employees, who can earn much more in jobs outside caring; they are also treated badly for the vital role they play. They do not have a nationally recognised training programme or an approved and registered qualification. The lack of a professional qualification or the prospect of career progression causes many to leave caring within the first 12 months. Some 10% of jobs are vacant—approximately165,000 vacancies are currently advertised—and high sickness and absentee rates are far too common. The picture I have described has been creeping up for years.
Will the Minister look again at how to make the careers of care home workers sufficiently attractive, so that we can retain as well as recruit them? Will he press for them to have professional qualifications after recognised training programmes, along with the prospect of career progression? Will he reduce the distressful level of bureaucracy faced by applicants for social care? If there is any more money—and quite large amounts were being bandied about last year that have not become visible on the ground—it should be focused where it would have most impact: on community and social care.
Baroness Boycott (CB)
My Lords, it is a pleasure to take part in this debate and, like everyone else, I thank the noble Lord, Lord Patel, for introducing it so brilliantly. I also congratulate the noble Baroness, Lady Ramsey, on a really good maiden speech.
This is an interesting week, in that we have decided to ban kids smoking. What we have not banned, and are in fact encouraging, is kids eating an appalling diet. We are flooded with unhealthy food, which is incredibly heavily advertised in all media. You only have to look at sport, and this year’s Olympics. The healthiest thing, everywhere, will be McDonald’s and Coca-Cola, yet we are worrying about our NHS. We must start having conversations with the food industry because if we do not, the NHS, which we all treasure and love, will creak under the strain.
I have lots of alarming statistics. I am not sure which ones to choose in the next four minutes, but here is one. Before the year 2000, there were no known cases of children in the UK with type 2 diabetes. There are now almost 10,000. All those children will be on the NHS books for the rest of their lives. They are also going to be ill. Let us look at it purely economically, rather than compassionately at what kind of life they will lead. They will not be working, not paying tax, not being good parents, not contributing to society. We can change this. I have been doing food politics for nearly two decades, and it amazes me that we have very little involvement with the NHS. We have very little involvement with doctors when talking about what people can do.
Do you know the main reason why most children under 10 go into hospital and have a general anaesthetic? It is to have all their teeth out because of the food they eat. We are also the lowest ranked country in the world for breastfeeding. My daughter, who has twins, managed to feed them for over a year. She had no help or support. I was astonished by the advertising she received from companies calling themselves “hungry baby” and stuff like that, absolutely trying to get under a mother’s skin and say, “Get off breastfeeding and get them on to formula foods”—foods which have higher sugar levels and set your sweet spot higher for the rest of your life. It is outrageous. There is almost no regulation. As for support with breastfeeding, for this young woman with twins, there was nothing. We paid for consultations to help her get through it and achieve that.
Is it any surprise that our kids are therefore growing up to be the most obese in Europe? As a country we are now the third most obese. No medical professional doubts what obesity does to our society, but they fail to connect it back to the food companies. Sticking with the baby food companies, all these little pouches they sell not only cost a lot of money but are extremely addictive to the kids because they are nice, they are handy and they convince mothers that they are doing the best for them, when in fact they are the root cause of them eating too much sugar.
The staggering profits made by the food companies every day are being paid for by the NHS. We are paying for it with our money and in the lack of care that nurses and doctors can give people. I am not saying that these people are not genuinely ill; they are, but from a preventable cause. The Government have had the balls to stand up to the tobacco companies this week. I know that this issue is more complicated than that—I can see the Minister looking at me—and of course we have to eat. However, there is a big difference between what we eat and how we eat it. We are just machines, like everything else. We need to put good stuff into the machine.
Unlike the noble Baroness, Lady Murphy, I had an extraordinary experience with the NHS. I managed to scald my foot and had a blister the size of a tennis ball. I ended up getting sepsis and was in the burns unit in Bristol. It was impeccable. However, in the lobby there was Costa Coffee and the Friends Shop. In the Friends Shop there was not one piece of fruit. It was cakes and biscuits all the way.
I got transferred to the Chelsea and Westminster Hospital for outpatient care. Again, the treatment was impeccable. Down in the lobby was bloody Costa Coffee—doughnuts and a long queue—and, in the Friends Shop, there was not even a grape. We have to start looking at this. As I say, no one would buy a Rolls-Royce, put Coca-Cola in the engine, and expect to go 100 miles down the motorway. We are not dissimilar, but we are even better than a Rolls-Royce. We deserve to put better stuff in. It is time the whole NHS and the country got this one straight.
Lord Carter of Coles (Lab)
My Lords, it is a delight to follow the noble Baroness, Lady Boycott. She certainly has a different view on things. I congratulate my noble friend Lady Ramsay of Wall Heath; she gave a tremendous maiden speech and brings great experience to this House, for which I am sure we will be very grateful. I was particularly struck by her comment on reorganisation, which I will return to later. We have had too much of that and a little less performance. I draw attention to my interests in the register. The noble Lord, Lord Patel, made a tremendous, and very knowing, opening speech. It was very clever how he went across the whole spectrum of things. I am perhaps a little less Olympian and will focus on one or two more narrow things.
Modern, high-performing healthcare systems are characterised by high quality, high productivity, and critical, consistent and predictable funding. That then leads to high patient satisfaction. This is being achieved in other parts of the world. For patients, it means access, rapid diagnostics, timely care and rapid discharge, preferably to home. How is that delivered? It is by providing the patient with a seamless journey along the continuum of care. Nowadays, that can be AI-enabled, but that needs an IT system that sits behind it to provide the single view of the patient. It is siloed, and it is very hard to deliver integrated care—I am sure that my noble friend Lady Pitkeathley knows this—unless you have a data system that gives you that access.
In other countries where such a system has been deployed, we have seen diversion away from hospitals—something many noble Lords have commented on. Between 20% and 40% of people simply do not need to go in; they need to be treated in other places. One encouraging thing—the National Health Service gets things right sometimes—is that the integrated care boards stand a chance of delivering this, but we have to focus and get on with it. It will take five years, but it needs to be done.
In the meantime, we must operate what we have a lot better. There are a number of things that are key to that: getting the primary care contract fixed; getting healthcare professionals facing up to patients much more on a substitution basis; and streamlining the primary care back offices. These are simple things—they are managerial, but critical.
Acute hospital productivity must rise, which the noble Lord talked about. Why did it take us so long—perhaps the Minister can say—to go back to payment by results? In a system that is desperate for activity, we went to block contracts, which is as close to lunacy as you can get. Can we go back to payment by results, and can we broaden it to encourage more providers, so that we get diversity of provision and also location? We need to move closer to the patient, and the only way to do so is to create certainty of payment through the tariff system. Those are the straightforward things that we can do.
I suggest doing two things. I have already talked about payment by results but, secondly, we must simply face up to the issue of delayed discharge. As happens in many other countries, we need the National Health Service to pay for the first 60 days post discharge. That would cut it all out and get people out of the hospitals. It is a very straightforward solution. It must be paid for at some point—but better that it is paid for and the arguments are moved out to somewhere else while people consider how to fund it. Long-term care funding and social care funding are, I think, matters for another day.
No healthcare organisation can truly be efficient and deliver at high quality if it has appalling staff morale. According to the last staff survey, only 44% of those employed in the NHS felt valued, which means that 56% did not. Some 25% felt bullied by their colleagues or managers. In most health systems, if that figure got to 5%, they would have the drains up. This is absolutely hopeless.
What all this comes down to is a management problem. We have had a lot of strategies; we have great strategies. Again, Ministers sort of knew what to do, so they commissioned the Messenger report. That report was absolutely tremendous, and had nine things we can do to fix things. Perhaps the Minister can tell us if those nine things will be implemented, because it is two years since the report was published. If we do not get the management right, nobody will put any more money in.
I am short on time, but I just share a little anecdote. If you have a group of NHS managers, and you ask them to name the 20 best-run hospitals in England, you get the usual: Northumbria, Chelsea and Westminster—despite the diet—Leeds and South Warwickshire. People can name eight easily; if they are lucky, they name 10. At best they name 15. There are 135 hospitals in this country. What does that tell us about the depth of management? The critical thing, therefore, if this is to work—I will shut up in a moment—is to get NHSE working properly. I am not sure that I will be as dramatic as the noble Lord, Lord Warner, but we must face up to the fact that we do not have a working management system. It is Soviet, and we are way past Soviet times. Let us hope that we can save the NHS and keep it free at the point of delivery.
Baroness Cavendish of Little Venice (CB)
My Lords, I pay tribute to the noble Lord, Lord Patel, his tireless work for the NHS and, as the noble Lord, Lord Carter, called it, his Olympian view across the system that he shared earlier. I too will focus on only one or two things. I am very glad that the Messenger report has been mentioned, and I echo the noble Lord’s question to the Minister, because it is two years since it was written. Gordon Messenger, as someone who served in the Army, really does know how to run a system.
I will talk briefly about two things beyond hospitals that other people have already talked about: prevention and social care. On prevention, to echo some of what the noble Baroness, Lady Boycott, said, my simple question to the Government is this: when will they fully implement the 2015 obesity strategy, written under the Cameron Government, which included, for example, broadcasting bans on unhealthy food? I would have thought that that would be a very simple question to answer. It has now been quite a long time since that report was written.
On social care, I was intrigued by something that the noble Lord, Lord Patel, said, which I had not expected him to say: he spoke warmly about long-term care insurance. I thought I would take my cue from that and talk a little about it. In the past few years, we have seen many interesting proposals for better funding of personal care. We have seen the cap, led by Andrew Dilnot, which is due to come into force in 2025 but on which I note that there is spectacularly little activity. I think that there is an opportunity now, post-Covid, with a public who are much more aware of the value of social care than they were before Covid. This has become a politically salient issue in a way that it was not before, because so many people have seen what care workers really do and how many of them stepped up to the plate. We saw people moving into the homes of older and disabled people, leaving their own families and putting themselves at risk. That made a big impact in a way that it had not before. The truth is that you do not understand what social care is unless you or a relative are in receipt of it. The vast majority of people in this country still do not really know what it is, but the polls show that people are increasingly aware that it is complex, patchy and deeply unfair. People are increasingly prepared to say that, yes, we need more money but we also need a new look at the system.
As others have said, the single-payer system for the NHS is the right and only answer. I do not think that that should be reopened, as the noble Lord, Lord Patel, said. However, there is an opportunity to look for a different model for social care. On the long-term care insurance point that the noble Lord made, Germany and Japan, two countries that I have studied in depth, spent several years having a deep conversation with their voters about a long-term care insurance system—it is slightly different in each place—in which everybody pays something in and everybody is able, if they need it, to take something out. That is a simple, transparent and sustainable approach that we do not have at the moment. What we see at the moment are battles over continuing healthcare, where the primary health need is not defined, and 40% of care home residents paying all their own fees and cross-subsidising other people with less money. I could go on, but we are all aware of the depth of unfairness in the current system. I simply ask whether the Government have any plans to look at other possibilities beyond the simple cap on care.
One of the problems—and I think one of the reasons why Andrew Dilnot, a great man, is so frustrated, and why successive Governments have not implemented the policy—is that it is very hard politically to describe to people a cap that is not a cap; it does not cap the bed and board costs. Imagine being a politician on the doorsteps trying to sell people what is ostensibly a cap on what they need to spend but it is not. It is very hard to deliver that. The other issue is that while it would obviously help people facing truly catastrophic costs, it would help only quite a relatively small number of people. Therefore, there is an opportunity to have a much bigger and wider conversation. However, I am afraid that that would mean going to the heart of an issue that is dear to many voters in this country, which is the question of their primary asset: would they be prepared, and should they be made, to sell their home to pay for care?
I note that Boris Johnson changed his language on this over time. He discovered—as everybody who looks at the issue does—that you cannot get a sustainable funding system while making no claim whatever on the homes of people who, yes, have saved to buy that home but, yes, may have also been lucky that their home value has increased. Will the Government consider, or do they have any plans to consider, looking at that alternative to the Dilnot cap?
Lord Parekh (Lab)
My Lords, the NHS is neither a leader nor a laggard, as shown in a comparative study of several countries. I think that broadly captures what many of us feel about the NHS. It embodies some fine values, such as equality of treatment, being free at the point of delivery of service, a strong incentive to regulate expenditure, and maintaining the self-respect and confidence of individuals that when they are in trouble they will be looked after and not have to worry about payment. All these are great virtues that the NHS embodies.
Sadly, it is also the product of its time. If you cast your mind back to 1948 and what followed afterwards, one begins to see an authoritarian culture where the experts know what is best. This is the ethos that is embodied in the culture of the NHS. For example, you can have a long waiting time and people do not see anything wrong with it, or no choice of the consultants or doctors you will see—it is decided for you—or your path to the consultant is already heavily guarded and not something that you can choose. There is poor investment in staff and diagnostic technology, so that you have machines for MRIs, CT scans and other things lying idle because they are supposed to be used only during working days. For all these reasons, we have reached a situation where the NHS does a lot of good and embodies a lot of good values but does a lot of work that many of us regret.
The NHS needs to be improved—radically, in some respects—and the question is not simply how we can maintain its sustainability; the question is whether we want to sustain it in its current form, what other changes we want to see made and whether those changes can be sustained over a period of time. I shall share my thoughts on this briefly.
The British people by and large cherish the NHS but not uncritically, which is why when they begin to discover its defects they increasingly become critical of it. Some 24% of people are heavily alienated from the NHS, and that number is increasing. That should be a source of concern to those of us who value the institution.
So how do we maintain the NHS? How should it be funded? We have relied on taxation as the source of revenue, and it is right that we should do that. I do not have time now, but I argue that compared to, for example, social health insurance or personal health insurance, taxation is a much better way. It gives the individual a sense of ownership of the organisation—he feels that this is his organisation because he has paid for it, and so on. Naturally, though, taxation is subject to party conflicts and divisions, and is never going to produce enough.
The revenue that taxation brings therefore has to be supplemented by other sources of revenue, but what other sources are available to us? There are two: reducing costs and increasing income in the NHS. When it comes to reducing the cost, one can think of a variety of ways in which expenditure could be cut. Lots of work is being done, for example, on why medicines for patients are lying unused—they are used for a day or two while the ailment lasts and then they are completely forgotten, and eventually wasted and thrown away. There are ways in which you can use electronic technology to alert the patient that it is time for him to take his medicine, and various ways in which you can control that.
On raising revenue, I was told by several people who have worked in this area in the United States and elsewhere, “Why don’t you have research, so that you have people who work with the NHS providing abundant data, with the state having access to these people and these diseases? Why don’t you have research done on this, resulting in innovations of medicines and instruments that can then be marketed?” It is not impossible for the NHS to think in terms of research scholarship.
I should have thought there were ways in which the NHS’s revenue could be increased and its expenditure decreased. That is the goal towards which the British public themselves seem to be moving. The NHS should be based on the principle of social solidarity but also have introduced into it the principle of personal responsibility.
Baroness Hollins (CB)
My Lords, I qualified as a doctor 55 years ago next month, across the river at St Thomas’. Much has changed since then—some good, some bad. I applaud my noble friend Lord Patel, and I agreed with his powerful opening speech.
As well as personal suffering, there is huge economic cost when the nation becomes less healthy. As we have heard, there are more than 2.6 million working-age people out of the labour market due to long-term sickness, at huge cost to the Treasury, with additional welfare and healthcare support and lost tax revenue. Yes, the NHS needs more investment, but it is not just about that; it is about changing the health and social care offer, improving access and equality of access, and changing the balance between hospital care and care in the community.
Italy closed its public psychiatric hospitals successfully, investing in 24/7 community provision. The Royal College of Psychiatrists asked that the next Government commit to a new health infrastructure plan for mental health, with one aim of improving the therapeutic environment of mental health and learning disability and autism in-patient settings, but it also hopes for real investment and the expansion of psychological therapies in early intervention and in public mental health.
The impact of negative press about the NHS and about social care has an impact on the morale and mental health of staff and the confidence of patients. This affects staff retention. A recent survey of 3,154 doctors by the General Medical Council found that 13% of respondents said they were very likely to move abroad to practise medicine in the next 12 months. A further one in three said it is very likely that they will move abroad at some time. This points to four key areas for improving retention: workplace conditions, pay, career structures and the perceived ability of our healthcare system to meet patient care needs.
Healthcare is a different and more complex service than when the NHS was founded in 1948. Individualised medicine is here to stay. More treatments are available, some very sophisticated and expensive. There is more bureaucracy, and we live in a more litigious world. The demands and expectations of the public have increased.
I read with joy an NHS pamphlet from 1948 which outlined to the public what they could expect from the NHS and, importantly, what the NHS could expect from them. I will quote a few gems from it. In my first quote, do notice mention of mental health:
“You will … be entitled to all forms of treatment in general and special hospitals, whether as an in-patient or as an out-patient. These include, for instance, maternity care, sanatorium treatment, care of mental health, and all surgical operations”.
About dental care, it says:
“You need no application form. Just call, by appointment, on the dentist of your choice when you need him … All necessary fillings and dentures will be supplied without fee, but if you want anything specially expensive … you will pay the … cost yourself”.
On maternity services, it says:
“It will be the doctor’s responsibility, with a midwife, to give all proper care and (if he considers it necessary or is called in by the midwife) to be present at the confinement”.
How wonderful it sounds. Perhaps we need an NHS pamphlet for 2024, to relaunch a new contract between the public and the NHS about what can be expected on both sides. I suggest that, as well as maternity care, we should have palliative care added to the 2024 pamphlet.
Central to solving the problems facing the NHS will be transforming social care from a safety net for people in vulnerable circumstances to a relational system that enables people to flourish. The endless gatekeeping, signposting and managing demand within the NHS all contribute to the increased demand for and greater complexity of social care. The bureaucracy affects unpaid family carers too, as I know only too well. Kate Garraway recently said about her experience of being a carer:
“If I have any regrets, it’s every single minute that I didn’t spend holding his hand because I had to go and write an email, make a phone call, fight the system that should be there to catch you when you fall but feels when you’re going through it like it’s there to catch you out”.
We need long-term thinking, long-term funding and more consistency, so that everyone—staff and patients—knows what to expect.
Care needs to move away from glamorous, expensive, interventionist hospital care and spend more in the community. If this does not happen, more expensive hospitals will need to be built to manage people’s acute needs that could have been better prevented or better managed.
Lord Londesborough (CB)
My Lords, I should first congratulate my noble friend Lord Patel on securing this critical debate and raising such challenging questions. Unlike many of today’s speakers, I am not a healthcare expert, but as an entrepreneur, employer and adviser to SMEs over the past 30 years, I have developed a particular interest in the health and productivity of our workforce, so I will start with the dismal subject of economics, as the long-term sustainability of the NHS hangs on the state of our public finances.
I sit on the Economic Affairs Committee, as does the next speaker, the noble Lord, Lord Davies of Brixton. Our current inquiry is also on the subject of sustainability, not of the NHS but of our national debt, which, at £2.7 trillion, has grown eightfold in just over 20 years. On current trajectories, neither the financing of our national debt nor our National Health Service can be considered sustainable.
Ever since the financial crisis 15 years ago, the UK has suffered from a low-growth, deficit economy. We consume more than we produce. That is an economic and health issue, the growing obesity burden being just one sign and inactivity another. Our tax revenues cannot keep up with our expenditure on public services, so we routinely resort to borrowing—an additional £100 billion or so added to the debt pile each year, to the point where last year’s interest payments on debt, at £120 billion, were only 30% less than our entire NHS budget.
Demographically, we have double trouble—an ageing population and falling birth rates. Our workforce has ceased to grow, in spite of immigration. The proportion of dependants is escalating. Without gains in productivity there is no real economic growth and no increase in our tax base, on which NHS funding entirely depends. This week’s data from the ONS makes for grim reading. The number of long-term sick off work has hit a record high of 2.8 million—an increase of 700,000 in just three years.
With an ageing and growing population, the demand on NHS services continues to outstrip our economic growth. Unless health tech or AI comes to our rescue, the next Administration faces the prospect of raising taxes further and borrowing more. What can be done to break this cycle? We must prioritise healthcare for both the long and short-term sick who have the potential to join or rejoin the workforce.
Following Covid, we now have a mental health pandemic. It is the biggest single factor behind the escalation in economic inactivity, yet the NHS is just not resourced to cope with this surge. There are many other conditions and disabilities that come high up on the list of causes of economic inactivity where waiting lists are growing or treatment is inadequate. These include musculoskeletal conditions, which have risen by 30% over the last three years—a reflection, perhaps, of an increasingly sedentary lifestyle.
Neurological disorders, which affect 11 million of us in this country, including me, are very high on the list and deserve far greater focus and resourcing. Shamefully, the UK has the lowest proportion of neurologists across Europe and the second-highest mortality rates. Indeed, the Economist estimates that in this field the consequential wastage of healthcare resource by non-specialist care, plus the social and economic burdens, are costing the UK £96 billion per annum. Against this figure, can the Minister say how much of the current NHS budget is devoted to treating neuro? I cannot find any reliable estimate of this figure.
Thanks to the Migraine Trust, I can share the data for just one of the most common treatable neurological disorders. The NHS devotes some £200 million to the treatment of migraine—a condition that alone costs £5 billion in lost working days. That is one example of a serious mismatch. We must make a much greater effort to align the NHS with the economy, for sustainability is a two-way street.
Lord Davies of Brixton (Lab)
My Lords, it is a pleasure and an honour to have been able to listen to this debate. I am happy to come in at this late stage with some additional thoughts. I thank the noble Lord, Lord Patel, for initiating the debate, and all the other speakers. In particular, I congratulate my noble friend Lady Ramsey of Wall Heath.
Putting your name down to speak in this sort of debate means getting a large number of briefing notes. I cannot claim to have read them all. Perhaps the Minister should commit himself to reading all the briefing notes and acknowledge the contribution they have made to our debate. A consolidated version of the notes would be a useful document.
Given the volume of material, there was obviously bound to be much that was missed from our discussions. I will focus my remarks on good mental health. I urge noble Lords to read the briefing notes from both the Royal College of Psychiatrists and the Mental Health Foundation. In the time available, I can touch on only some of the points arising from their submissions, but I think they are important and should be read.
I want to make three points. First, there is a considerable cost of poor mental health. I emphasise that measures are available that can tackle those problems. Providing healthcare is not just about the financial return, but when we can spend relatively limited amounts and get huge benefit, we clearly need to take that into account. Secondly, the focus in this area has to be on prevention. The value of measures aimed at prevention is considerable and will be effective across the whole health service. Thirdly, I mention the importance of undertaking more research in the area of mental health.
I take the opportunity to stress again the importance of getting a mental health Act through the House. Presumably, we will now wait for the next Session. An incoming Labour Government, if we have one, are committed to doing that. The problem is that the problems assessed by Sir Simon Wessely six years ago are still there. The Act is a symbol of the intention to deal with the problems he identified.
What measures could we adopt? What measures do we need to think through? They are all set out in the submissions and there is not enough time to go through them all. Poor mental health among the workforce has been touched on already. According to the research we have been provided with, that is where £1 of expenditure provides £13.62 in improvements. This bears directly on the overall health of our economy. Individual health is very much the health of the economy as a whole. The £118 billion that poor mental health is costing us—that is 5% of GDP—is an obvious and clear target for work across the important area of poor mental health.
Lord Mawson (CB)
My Lords, I thank the noble Lord, Lord Patel, for this timely debate. My colleagues and I at the Bromley by Bow Centre have been at the cutting edge of innovation in primary healthcare for 35 years. We entered this space by accident following the tragic death of a local resident, Jean Vialls, in an East End housing estate in May 1991. Jean’s death led to a senior-level inquiry at a London hospital, which picked apart the lives of an East End family in very challenging circumstances who had been badly let down by the NHS and its siloed culture. The inquiry also challenged the NHS on its lack of attention to detail, its management systems and its culture, which had forgotten who the customer was. Sound familiar.
We were told at the time that lessons would be learned but, 35 years on, I can assure noble Lords that few lessons have actually been learned by the NHS. Indeed, my GP colleagues tell me that getting up stream and creating more integrated responses to health needs gets harder to do, not easier. In the course of this well-documented and tragic encounter, we began to realise that in poor communities at least 70% of the determinants of health are social and not biomedical; they have nothing to do with doctors. The NHS business model was absolutely the wrong way around and there was a desperate need to get up stream into the prevention agenda.
Our practical response, as an increasingly entrepreneurial culture took root in Bromley, was to build the first working model of an integrated primary healthcare centre that moved beyond just health and social care and embraced housing, employment, business, the arts and education, and so on. We have created 97 businesses with local people over the years. We started to join the dots. Even with the support of the then Prince of Wales, now the King, this work was done against a prevailing culture in the NHS that talked about innovation but rarely grasped the nettle. Today, the Bromley by Bow Centre is responsible for 55,000 patients on four sites, and has been taken national through the Well North programme, which I lead—here I declare my interest. The centre today hosts 2,000 visitors each year, from across the world. There has been all this work and learning, but so little in practice has actually changed. One hospital medical director we work with described the NHS as a blancmange when it comes to innovation: it wobbles when innovative ideas and practice are first introduced but always returns to shape and form. This is not a sustainable culture.
What needs to be done? Here are seven brief steers, based on many years of practice. First, we must stop treating the NHS like a religion and be honest about its condition: it is ill and broken. Business as usual is not an option. It needs radical surgery over a 10 to 20-year period.
Secondly, we need cross-party agreement to stop the constant meddling of countless politicians and endless restructuring. I was involved in the 2012 Olympics programme for 19 years, from day one. Our focus was on creating a real legacy in east London from this once-in-a-lifetime opportunity. Early on we focused on gaining cross-party support for a 25-year programme—go and have a look at the results.
Thirdly, we must take seriously Dr David Haslam’s concern that if we carry on with the present NHS business model, it will absorb 100% of GDP by 2070. It is not sustainable; we are creating a dependency culture.
Fourthly, we must create a learning-by-doing culture, and move away from so many expensive, outdated reports that few read.
Fifthly, the modern world is about people and relationships, not processes, and so we must nurture them at all levels of the NHS.
Sixthly, technology is not the answer to everything but it is a fantastically useful tool. We must start small, interfacing the technology with people and their practice, and use it to grow organic cultures that work. Stop trying to land big solutions from above.
Seventhly, we have always found, right across the country, individuals and localised groupings that were able to deliver this more joined-up, entrepreneurial approach. At the moment, this is true, for example, in Bradford, York, Rotherham and east London, among others. However, they are not in general supported and encouraged, and thus the approach does not become established more broadly. As has recently been observed, the NHS has more pilots than British Airways—why not get behind these good people, long-term, and build a culture based on innovation, integration and entrepreneurship.
My question to the Minister, and to the Opposition if they were to come into government, is this: given the present spending trajectory and business model, what percentage of the UK’s GDP does the Government estimate that the NHS will soak up by 2070, and what are they doing about this challenge? Who in the department is thinking about this problem?
Lord Hacking (Lab)
My Lords, I normally do not put my name down for specialist debates such as this one, because I do not possess the necessary expertise. That is certainly true for this debate, although during the past two hours I have learned a lot. However, there are two reasons why I wish to address your Lordships.
The first is to recall the foundation in 1948 of the National Health Service, one of the two great social reforms of the Labour Government of 1945 to 1951—the other being legal aid, which, alas, has now almost withered away altogether. I was only 10 years old in 1948 when the National Health Service was introduced. I remember it very well.
The second reason why I wish to speak is that I believe we should understand the current challenges of the National Health Service and praise it for its successes. That has certainly, to some extent, come out in this debate. It is touching to remember that the National Health Service was designed in its origin to save money for the economy, almost to the point of being financially self-sufficient.
Where are we now in the debate? I will summarise, if I may, as a speaker at the very tail-end of the speeches, where I think we are. Since 1948, we have had the benefit of the provision of more and more wonderful techniques that have helped us remain in health. The problem has been that, for this, we have needed more and more expertise and more and more persons to operate those techniques. The result is that there are more and more specialists among doctors and among all those who give their support to doctors. For example, there are nurses who are highly skilled and highly trained in oncology, supporting the doctor oncologist. Similarly, there are radiographers supporting the doctor radiologists in the great range of MRI scanning and so forth that is now available. The result is that lots of things are being done, and have been done, much to our benefit.
I will speak of my personal experience of heart treatment. Fifty years ago there was no open heart surgery and no use of stents. My father died when he was 60. I have the same heart condition, and I had a large bypass operation 30 years ago and am standing now before your Lordships.
We should recognise that lots of people in the National Health Service are working very hard and doing well. I cite one example of that, on the Guy’s and St Thomas’ NHS Foundation Trust website. I happen to be a patient of that trust, and the website includes what it calls MyChart, which is easily accessible and provides an awful lot of very important information that you need as a patient, such as when your next appointment date is.
I end my short address to your Lordships in this way. I believe that we should give praise to the National Health Service, and I invite the Minister to do just that when he stands up to speak. An all-party alliance must be planned to decide the future of the National Health Service, a point that has been very well made in this debate.
Lord St John of Bletso (CB)
My Lords, I join others in thanking and congratulating my noble friend Lord Patel on introducing this topical debate, and in congratulating the noble Baroness, Lady Ramsey, on her very moving maiden speech.
As the last to come to the crease before the closing speeches, I shall be very brief, and just make a few observations. I come to this debate not as a medical expert, though like my noble friend I suffer from peripheral neuropathy, but for the past 20 years I have been a company doctor, fixing companies large and small, though not on all occasions helping them to become more efficient and profitable. My first observation on the NHS is the apparent failure of effective leadership. I know many GPs, specialists and junior doctors, and one junior doctor I spoke to yesterday commented that he had been on strike not just because of the money but because he and others felt disfranchised.
We live in an exciting time of digital transformation and artificial intelligence, and we are seeing huge advances in quantum computing. By analysing vast amounts of medical data, including electronic health records and genetic information, we can uncover patterns, predict outcomes and improve diagnosis and treatment. Ultimately, however, the focus must be on effective, adaptable and accountable leadership. There is a danger that many in the medical fraternity are too focused on following protocols rather than guidelines and get bogged down in red tape.
I recently read the book, 2030: The Future of Medicine by Professor Richard Barker, a specialist in longevity research. I mention as an aside that it is my noble friend Lady D’Souza’s 80th birthday today—happy birthday. At 80 in your Lordships’ House, she is but a youngster. The observations that Professor Barker made when he wrote this book in February 2011 pertain as much today as they did then. In essence, he called attention to the need to re-architect the NHS and provide more effective time management to NHS GPs. Many GPs complain that they spend far too much time on administration and far too little time using their medical skills to diagnose and treat acute conditions. In this regard, a lot of elderly patients are not getting the treatments that they need and deserve. One of his observations was the need to focus on preventative medicine. We have seen huge advances in oncology and cardiology, but a lot more can and should be done on preventive medicine, including more focus on tackling obesity, on gut health and on lowering cholesterol.
The noble Baroness, Lady Blackwood, spoke very eloquently on the profound impact of genomics on personalised medicine. With the ability to sequence entire genomes rapidly and affordably, we are entering an era where treatments can be tailored to an individual’s genetic make-up, leading to far more effective, targeted therapies.
Time precludes me from debating the need for more effective procurement within the NHS. A huge amount could and should be done to save costs through shared services. I agree with my noble friend Lord Kakkar that the long-term sustainability of the NHS is a joint effort and requires commitment from all stakeholders—the Government, healthcare professionals, patients and the public sector. Will the Minister, in winding up, advise us as to what measures have been taken to conduct a global best-practice study on the long-term sustainability of public healthcare? I agree with the excellent suggestion of my noble friend Lord Warner of assimilating the Singapore healthcare system.
In conclusion, there are a lot of positive developments in the NHS and people should be congratulated and appreciated for their hard work, but my call is a simple one: we need to focus on effective and adaptable leadership, on effective procurement and on patient care; and to continue to focus on prevention. More funding in the NHS does not necessarily solve the problem. We need to get smarter.
Lord Allan of Hallam (LD)
My Lords, I am very grateful to the noble Lord, Lord Patel, for this opportunity and for the reminder of the time of the coalition Government, which I think we might accurately describe as the last sustained period of strong and stable government that we had in this country. It is a moment to remember the work done by my friend Norman Lamb, who I think was recognised as an excellent Minister for mental health and care. Essentially, the good bits were ours and the bad bits were theirs, including the pointless NHS reforms, and that is all we really need to reflect on with regard to the coalition Government.
I have enjoyed hearing a wide range of interesting contributions, including those from my noble friends Lord Scriven and Lady Tyler. I was also very moved by the excellent maiden speech of the noble Baroness, Lady Ramsey of Wall Heath. I share with her having two children born in St Thomas’s Hospital, although, unlike her, I did not have to do the hard work: I was a mere spectator.
I will not cover the issues to which others have applied their much greater expertise but focus on the role of information technology, on which I have some expertise and which has become universally recognised, including in this debate, as a key enabler of the productivity increases that we need in order to make the NHS sustainable. The noble Lord, Lord Kakkar, called for areas where we could have cross-party work; I think this area is particularly conducive to that. I and most geeks do not really care who is in government. We have the phrase, “Code wins arguments”. Unfortunately, elections do not work that way but, in the world of code, if you design a better product that runs more quickly, that is the one you should implement. There is a large community of people who believe in the NHS and can apply those technical skills but do not care who is in government. I ask the Minister whether we could make immediate progress in that area with a non-partisan approach.
I want to talk not about whizzy, cutting-edge technology, which we often go into, but the foundational elements where some of the biggest gains could quickly be realised, because there is a large amount of low-hanging fruit. I will raise five areas with the Minister—essentially, layers that together would form a platform for improved services.
First, we need a comprehensive catalogue of the collection, storage and use of data across our social care and healthcare systems. That does not exist today. The noble Lord, Lord Carter of Coles, referred to this; we do not have a comprehensive catalogue so there are enormous inefficiencies built into the system. There is a natural tendency when building technology to look at the shiny front end and at apps, but that is useful only when you have the back end set up properly. For the NHS and care, that is frequently not the case. It is the boring bit, but it is essential that we walk through and audit all the many systems that we use and document our data. Openness here can really build trust. If people out there can see who has what data and what they are using it for, that will generate trust. When people see it as a black box, trust dissolves and they start to withdraw their consent. An open database is essential.
Along with that, we need openness around the processes and tools used to work with that data. These days, a lot of the code can be open. You can make it reusable. We could reasonably aspire to a position where a new entrant into the market could say to a service such as ChatGPT, “Here’s the data model, some example code and the processes—build me a system”. That is where we will get increased competition in areas such as GP systems, which have come to the fore these days. There are two major suppliers and people ask why there are not more. We could make it a lot easier for people to come in and compete not only on cost but, importantly, with innovative features. We do that by making sure that the data model, the processes and the code base are open.
Once you have that foundation sorted out, the third area is thinking about the content and messaging. There is a very current debate about the fact that online platforms such as TikTok are really good at getting people to engage with them. We see that as devious and dangerous behaviour, but that is what we need in the NHS. When running a screening programme, you want the kind of skills that get people to click on it and sign up for the appointment. We saw some of that with the encouragement for Covid vaccinations, but we get a hell of a lot of other communication from the NHS that is not of that quality. If you are going to set up a screening programme, it is a real waste not to have the kind of skills you need. Software engineers—my profession—are not the people to write this stuff, but a lot of the stuff we get looks like it was written by them. There are really good people who know how to get people to engage, which is what the health service needs. As a general maxim, the systems we use to engage with our healthcare should be at least as good as the ones we use to share cat videos—and I think healthcare ranks a little higher in importance. We can all see that the gap is enormous at the moment.
The fourth area is around ownership. Committees do not own things; named people own things. In the tech sector, when you want something delivered, you say to somebody “Here’s your target—you need to deliver this product”. Often, working in a massively matrixed organisation, you need to get lots of other people who do not work for you to deliver the product, but you need to know who the person delivering the product is and not allow it just to be put into a committee where everyone can pass the parcel.
It requires persuasion, support and, crucially, a service culture. It was interesting that the noble Lord, Lord Hunt, said that “people hate NHS England”. That is a real problem if NHS England is signing up and buying services, such as the federated data platform, and it has to roll them out to a massive variety of organisations—some of them are brilliant; in some, there are two IT support people who are busy trying to help people change their passwords—and you come along and say, “Can you implement this system?” Well, they can, if someone helps them to do it. We need somebody, somewhere, to have that kind of service culture—somebody who owns it and has the tools to say, “I need to get that trust to implement the system, and the way I am going to do it is not just by sending out a directive. I am going to go and hold hands, and help them, and find out what the barriers are. I don’t care what they are—I am going to address them”.
The fifth element has come up in discussion today: integration with other systems. I sometimes feel there is a nervousness about talking about stuff that is outside the NHS. Increasingly, that is where people are; it has been said in the debate today that people might be consulting an online GP service. We have negative phrases such as “worried well”. I think it is quite nice to be a bit more worried about your blood sugar level or diet, or about lumps and bumps where we should not have them. There is a range of things we should be worrying about, and we have opportunities to get tests done, but there is very little integration between all that and the core NHS. That is something we could fix; again, it is one way to make it sustainable. In many cases, we—or our workplaces—are paying for health check-ups. If the system is right, once we have collected the data, let us get it integrated. We have systems such as Patients Know Best, which are trying to do this. These have been paid for, but they are not universally rolled out and in use.
To pull all that together into an example, let us think of something really boring and old fashioned, like blood pressure checks, which the noble Lord, Lord Patel, rightly raised as a key way of stroke prevention. If you have a standard data model for how to deal with blood pressure checks, or if you had standard code for how it is collected—on a phone or in a private clinic—and put into your record, and if you had an owner of a blood pressure screening programme whose job is to get 80% of the target group screened once a year, we could say, “We do not care how you do it, just be creative and figure out what is the right way. Is it text messages? We don’t care, as long as you get that 80% data”. If it was integrated, that person’s job would be to hustle, hassle and help people, and to work with all providers of mobile phones and workplace networks to get it done. That is the kind of thing that could make a difference.
I hope it is helpful to the Minister to describe a model that could be applied more generically across a lot of the challenge areas that the NHS faces. At the moment, a lot of people know what “good” looks like and what they want, but the structure militates against it because responsibility is too widely distributed, and there are too many people doing individual things in silos. At the moment, the only model we have to overcome that is a directive from NHS England. That is not what you need; you need detailed grunt work on the ground to get us from where we are today to where we want to be, which, as a patient or an NHS staff member, is using systems at least as good as those we use to share cat videos.
Baroness Merron (Lab)
My Lords, I congratulate the noble Lord, Lord Patel, on securing this debate and for introducing it with his characteristic authority, insight and care, with which we are so familiar in your Lordships’ House.
I am delighted that my noble friend Baroness Ramsey of Wall Heath chose this debate in which to make her excellent maiden speech. How proud her mother and father would have been today, and what a difference she made to the life of her late sister, and, indeed, to the National Health Service; and what a difference I know she will make to your Lordships’ House.
To give some context to the need for long-term sustainability, over the last 14 years, as we have heard, the health service has acquired the undesirable distinction of having the longest waiting lists, the lowest patient satisfaction and the worst strikes in its history. The noble Lords, Lord Patel and Lord Kakkar, not only described the harsh realities and inequalities of the current systems but asked what all parties would do about correcting it. I am flattered to be invited to give some flavour of how an incoming Labour Government—if there is to be such a thing—would approach the challenges ahead.
On that point, I am glad that my noble friends Lord Hunt and Lord Reid and the noble Lord, Lord Crisp, recognised the positive impact on the health of the nation of the last Labour Government, in which I had the honour of serving as a Public Health Minister. That allows me to say to noble Lords, including the noble Lords, Lord Bethell and Lord St John, and the noble Baronesses, Lady Boycott and Lady Finlay, that, when it comes to prevention and a focus on the broader improvement of health, I am totally signed up.
My noble friends Lord Hacking and Lord Parekh have brought a welcome analysis to today’s debate. I agree with my noble friends Lord Hunt and Lord Turnberg and the noble Baroness, Lady Hollins, that bullying, burnout and pressure on the workforce is no way to retain or get the best out of people—we need only talk to people in other sectors to remind us of that.
This change will require a change in culture on so many levels. The noble Lord, Lord Crisp, spoke of the fundamental need for shared vision, hope and energy. It struck me that they are exactly what is missing at present in health and social care. As we have heard today and so many times before, social care is inextricably linked to the health service. I remind any incoming Government, including a Labour one, that there are a number of first-rate and considered Lords reports, including on social care, primary and community care, and long-term sustainability. Therefore, any Government would be extremely well advised to delve into them. Wes Streeting, shadow Secretary of State, has been very clear about the measures that need to be taken on social care, emphasising the need for long-term planning, thinking and funding.
The right reverend Prelate, the noble Baroness, Lady Cavendish, and my noble friends Lord Turnberg, Lady Pitkeathley and Lady Warwick were absolutely right to speak about the invisibility of unpaid carers and the poor treatment of employed care staff. That is not sustainable—and neither are the record levels of sickness and long-term conditions that affect the workforce, which my noble friend Lord Davies and the noble Lord, Lord Londesborough, spoke about so clearly.
I do not consider myself a technological expert, but rather a technological convert, which I am sure the noble Lord, Lord Allan, will be very pleased to hear. So I have looked to countries such as Israel, which I believe to be at the cutting edge, which is where the UK needs to be. At the emergency department of the Sourasky Medical Center, people register digitally, identify themselves through facial recognition and measure their own blood pressure, temperature and heart rate in self-triage booths. Patients are given a barcode and a number is sent to their phone, which they can track on a screen. The most serious cases are seen within minutes, and virtually no one waits more than an hour. Last month, this Tel Aviv hospital became the first in the world to integrate an AI chatbot into its triage process.
What is the driving force behind that? This Israeli hospital is designing healthcare around the needs of the patient, which my noble friend Lord Carter and many other noble Lords called for. Sadly, that is very much in contrast with Britain, where our NHS reels from crisis to crisis, while the political debate circles around funding, staffing and pay. The way that we bank, shop, travel and work has been digitised in the past decade, yet the NHS remains largely outdated. There are multiple IT systems in the NHS and no requirement for them to be interoperable.
That means that systems cannot talk to each other, sometimes even within the same hospital, let alone between institutions or between primary and secondary care. There are at least 21 different types of electronic patient records in hospitals and 34 apps to book an appointment. No company would be able to survive with productivity like this, as the noble Baroness, Lady Tyler, said. Let me ask the Minister: how has the Government allowed the NHS to develop like this?
NHS England’s digital lead, Joe Harrison, estimates that every pound spent on technology generates between £3.50 and £4 in savings. Such an approach makes sound financial sense, as well as good health sense. While the case for reform is overwhelming, too often the innovators are thwarted by a fragmented system or vested interests. What is being done to overcome this?
We know that an estimated 13.5 million hours of doctors’ time is wasted every year due to inefficient IT. Fixing that would be the equivalent of 8,000 new doctors joining the NHS. That is the difference between the huge staff shortages that we see and filling almost every vacancy for a doctor. With our country’s population ageing, the health of the public worsening and chronic disease rising, the sustainability of the NHS is crying out for change.
I recently went to the National Theatre’s production of “Nye”, as I know many other noble Lords have done. When he created the NHS in the 1940s, Nye Bevan had absolutely no idea of the scientific revolution ahead. Regrettably, if we dropped Nye Bevan into the NHS today, he would see the modern-day pressures of an NHS that is overly hospital-based and gets to patients too late, at greater cost and with worse outcomes.
If Labour does get into government, we will arm the NHS with the modern technology it needs, doubling the number of scanners, and putting AI into every NHS hospital, so that patients are diagnosed earlier. We will get rid of the unnecessary bureaucracy whereby innovators have to tout their technology to each individual NHS trust; we would stop the need to sign separate agreements with each of them. We will streamline the route in for innovators and put the entire NHS in partnership with the technology and life sciences sector.
Following the pandemic, more than 32 million of us carry the NHS app in our pockets. That provides the potential to transform how the NHS interacts with patients, promotes good health and increases people’s control over their own healthcare. We would make the NHS app not just something to assist the NHS in healthcare but a key component in delivering care—both preventive and curative—and empowering patients.
Finally, what do the health and care leaders want? They know that investing in primary and community care results in a lower demand in hospital emergency care. For every pound invested in the NHS, £4 comes back to the economy. The greatest economic returns come from investing in primary and community care, where we see a £14 economic return for every pound invested. If Labour is to be in government, this is the step change that we will make.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Markham) (Con)
I also thank the noble Lord, Lord Patel, for initiating this debate today. I am very happy to start off by answering the question of the noble Lord, Lord Hacking, by praising the NHS. The very ethos of the debate that the noble Lord, Lord Patel, brought up today is that, as critical friends, we know that we need to look at the challenges that the NHS is facing if it is going to be sustainable for the next 75 years.
I welcome the noble Baroness, Lady Ramsey. I enjoyed her journey and I shared some of her difficulties in finding her way around this building. I think I sum up the views of the whole House by saying that we are delighted that she has found her way to be with us here today and, generally, in the House of Lords.
I also thank all noble Lords for the constructive way in which this debate has taken place. Again, I praise the noble Lord, Lord Patel, for the way he framed this whole debate to bring that about. There were a lot of very thoughtful contributions, and in many ways we built on the debate that the noble Lord, Lord Scriven, called about six or nine months ago—this debate was very much in keeping with that. I particularly enjoyed the passion that the noble Baroness, Lady Boycott, brought to it all. I thought that at this stage I probably should not declare an interest in Costa Coffee—which I do not have, by the way. There were very many thoughtful contributions which I hope I will be able to build on, but I single out those by the noble Baroness, Lady Murphy, and the noble Lord, Lord Warner.
I want to avoid this being a political debate. Maybe contrary to some of the points of the noble Lord, Lord Hunt, we are seeing similar challenges across all four NHSs—across all four nations. I am afraid to say that maybe the worst-performing of those, from the records that many noble Lords will remember, whether we are looking at waiting lists or a number of other records, was Wales. These are challenges that we are all facing at this point. However, I want to be united in this debate in looking at the positive way forward.
I recognise that many noble Lords, including the noble Lords, Lord Hunt and Lord Warner, and the noble Baroness, Lady Murphy, brought up the overcentralised nature of the NHS. However, I disagree with the noble Lord, Lord Hunt, that this is due to direction from Ministers. The whole point of trying to set up the ICBs, as referenced by the noble Lord, Lord Carter, is to reverse that and put more power at a local level. These are early days in the life of ICBs but we definitely see them as the way forward.
I hope to answer the points made by the noble Lord, Lord Kakkar, and the noble Baroness, Lady Cavendish, on trying to make this into a long-term conversation. I freely accept that probably at this part of the political cycle we can have only so much of a conversation. However, on my part, whichever role I may or may not be in post election, I undertake to take part with whoever is in power in what I hope will be a constructive conversation. It needs to be the sort of environment where, as the noble Lord, Lord Allan, says, code wins the argument, and people are coming from all around and can have those sorts of constructive conversations. I think that will include a new contract between the NHS and the people, as the noble Baroness, Lady Hollins, says.
I will start by echoing some of the financial realities that the noble Lords, Lord Bethell, Lord Mawson and Lord St John, brought up. The reality of the situation is that we spend about 10% of our GDP on the NHS right now. It is going up as a proportion year after year, and it will go only one way. At the same time, no one is proposing major injections of cash. I think we all recognise the financial situation; the proposals that Labour made, for instance, amount to less than 1% of the NHS budget. Therefore, I think that what we can all unite on right now is that this is an argument not about pumping in lots more money but about finding other ways to try to make the NHS more sustainable, in many ways using, as the noble Lord, Lord Warner, says, a “tough love” approach where that is appropriate.
I want to talk about the things we are doing in terms of the infrastructure and capacity, as the noble Baroness, Lady Murphy, mentioned. When I talk about infrastructure and capacity I am talking about the labour supply, the productivity plan and the capital estate, and I then want to combine that with the new way we need to engage, whether it is around technology, prevention or primary community care, which to my mind are the ways in which we will create a sustainable NHS going forward.
Starting with the labour supply, I completely agree with the point made by the noble Lord, Lord Hacking, that staff are at the heart of every successful organisation. That begins with making sure that we have the right number of staff, which is what the long-term workforce plan is all about—trying to make sure that we have the proper recruitment, training and long-term resources.
However, more important than any of that are the points about retention and the right culture, made by the noble Baronesses, Lady Hollins and Lady Finlay, respectively, so that people feel that they are valued and are in a caring and supportive environment rather than the bullying environment we have seen all too often. In answer to the questions from the noble Lord, Lord Carter, and the noble Baroness, Lady Cavendish, I say that the Messenger report is vital.
The role of management is fundamental. In answer to the question from the noble Lord, Lord St John, I can say that when I first came into this, I did a lot of work trying to look at hospital performance. I did all sorts of analysis, looking at demographics in a local area and the relative funding. No matter what I did, there was always at least 50% unanswered in the multiple regression analysis and so on. The conclusion I came to, which is probably not earth-shattering, was that that 50% performance is all about the management, leadership and culture that drives it.
As the noble Lord, Lord Kakkar, said, a lot of that is allowing people to work at the top of their profession. If you allow them to do that, that is when they can make the new developments and innovations. That means using technology and AI to help reduce administration, which I will come to later when I talk about the productivity plan. It will also mean some uncomfortable conversations, using other staff to do some more of the administrative parts. Again, I totally support, welcome and appreciate the moves that the noble Lords, Lord Hunt and Lord Scriven, are making in the use of things such as physician associates, which is about trying to take away a lot of that burden so that doctors really can practise at the top of their profession.
In response to the point made by the noble Baroness, Lady Tyler, about productivity, that needs to be and is being put into a detailed plan that we can all review. We will have the opportunity to do so around July. As the noble Baroness, Lady Merron, said, we absolutely identify that we need to replace the inefficient IT estate, among other things. It is doing a lot of the basics in PCs, wifi and all the things mentioned by Joe Harrison, whom I know well; I work with him every week. It is about systems, EPR and arming the staff and clinicians with the basic equipment. You can start small, as the noble Lord, Lord Mawson, said. As well as electronic patient records and the FDP, those are the things from which we will get productivity improvements. When I talk about figures such as the £35 billion, I am talking about increased output, not savings. I am talking about how we can get increased treatments and output—and definitely by using the things mentioned by the noble Lords, Lord Reid and Lord Carter: payment by results and the right incentive systems; and, as the noble Lord, Lord Crisp, said, the use of the independent sector to supply, where relevant.
Of course, vital to all this is the capital estate. That is why the new hospital plan is a vital part of this. The work shows that if you put the right digital instruments in place and the infrastructure into hospitals, you get 10% more productivity. In answer to some of the questions from the noble Lord, Lord Warner, I say that if you put the right real estate in as well, the combination gives you 20% more productivity. That is not just time output but reductions in the length of stays. We all know that the sooner you can get people home, they are more likely to go on and live successfully in their environment.
Regarding the points around adult social care and the training and qualifications of the staff, which were made by the right reverend Prelate the Bishop of Newcastle, the noble Baroness, Lady Warwick, and the noble Lord, Lord Turnberg, I totally agree. That is what we are trying to do. We have for the first time introduced a qualification for adult social care staff and training. We have put 18,000 different adult social care providers into a system where they can put up training and get easy management of payments for it all. More needs to be done long term for a fundamental funding model; that goes to the points raised by the noble Baronesses, Lady Warwick and Lady Cavendish. That will involve a covenant of care but, honestly, we need to do more work on long-term funding solutions.
I cannot say enough about prevention. My noble friend Lord Bethell said to me, “Very simple, your speech today: prevention, prevention, prevention”. There are a few more things but I will definitely add a few “preventions”. The long-term workforce plan and productivity plan are designed towards that. The screening programme that we are doing is because Chris Whitty’s biggest concern is that simple things such as blood pressure which were missed during Covid will now lead to excess deaths in heart disease. As the noble Lord, Lord Patel, mentions, those simple blood pressure measures and mid-life MoTs are fundamental to what we are trying to do. I will take a leaf from the book of the noble Lord, Lord Allan, because it is right: we need the champions in that space.
I agree with the points made by the noble Baroness, Lady Boycott, on the importance of dentistry and early check-ups being needed for the prevention agenda. Our new plan regarding school checks and water fluoridation is all to help with that. I see a future world, of which I will talk more later on, where you have a much more targeted screening programme. In addition to our mid-life MoTs, which are blanket programmes, AI needs to be used to help target screenings so that we can really help people in prevention.
I agree on the ever-increasing use and funding of acute hospitals, which none of us has solved, as raised by many noble Lords. There is a need to rebalance this towards primary and community care. I look forward to the report of the committee of the noble Baroness, Lady Pitkeathley, on the integration of it all and what we can learn from its points. Things such as Pharmacy First are good ways ahead. We have seen 98% of pharmacies sign up and already there have been 125,000 consultations. With the dental plan, we have had 500 new surgeries and a 50% increase in the numbers taking adult NHS patients. However, we need the new model of care mentioned by the noble Lords, Lord Scriven and Lord Crisp, care that is away from the acute hospital and in the community. I cannot speak more highly of the Bromley by Bow Centre, which I visited. The noble Lord, Lord Mawson, should be very proud of everything that I saw there. Of all the visits that I have done in almost two years in this job, it was one of the ones that I enjoyed the most and was most impressed by. That is the model we should take going forward.
That centre is doing exactly what the noble Baroness, Lady Chisholm, mentioned, in looking at the whole health of the person and seeing how it can really care for them in the community. Of course, that requires community nursing. My mother was a community nurse, so I realise that. It needs to be backed by technology. I am proud to say that I have been responsible for the app for the last 18 months and we have gone from 10% of people having their medical records to over 90%. As the noble Baroness, Lady Merron, said, we now have 33 million people using the app for digital prescriptions, medical records and appointments, which the noble Baroness, Lady Pitkeathley, had an example of just the other day.
We do need to broaden things out, so more people realise all the features that are on the app, but we really do see the app as the front door of access to the NHS. It will deal with future therapies, whether musculoskeletal, as many noble Lords have mentioned, or mental health. That gives opportunity for it all. On the point made by the noble Lord, Lord Parekh, the app does allow people to take control and to take power away, sometimes, from the experts, giving them control and putting the power in their own fingertips.
Data and AI are fundamental to this, to enable the sort of precision medicines my noble friend Lady Blackwood mentioned. I thank her, and Genomics England for all the work it is doing to lead on this. It is an institution we should rightly be proud of. That is the future of medicine, but it is all underpinned by the data. Funnily enough, I have kicked off cataloguing of that, because it is fundamental.
On adult care, we have increased digitisation from 20% to 60% quite quickly. Having the data at the heart of this will allow competition and innovation to take place. But we need to make sure that that conversation happens in the right way, so that we bring the public with us on that journey.
I hope that gives a vision of the things we are trying to do to put the infrastructure in place—the supply, workforce, technology, IT and capital—accompanying that with new ways of working, whether it is a focus on prevention, more input into primary and community care, or using AI, technology and genomics to lead the way forward. I think we all agree that that is the only way we will get a sustainable health service going forward.
I thank the noble Lord, Lord Patel, and all noble Lords who have contributed for the spirit of the debate and its thoughtfulness. I give special thanks again to the noble Baroness, Lady Ramsey, for choosing this debate for her maiden speech, and I thank the noble Baroness, Lady D’Souza, for joining us on her 80th birthday. As ever, I apologise to those whose contributions I have not managed to cover completely, and I promise to write giving a thorough wrap-up.
Lord Patel (CB)
My Lords, the new rules do not allow me to speak at length, so I am constrained. I truly am constrained, because I would have loved to dissect some of the speeches made by some of my friends. I wish that the hospital, wherever it was, had treated the noble Baroness, Lady Murphy, better, because her speech might have been different. When I put in a bid for this debate, I did not imagine that I would get the talent pool we got today, or the brilliant speeches that have been made. Top of the list, of course, is the maiden speech by the noble Baroness, Lady Ramsey of Wall Heath; we look forward to hearing her over and over again.
I had intended that this would not dissolve into a political debate, and I am glad that it did not. I am glad that my challenge to all three Benches paid off. By the way, I say to the noble Lord, Lord Allan, that it was this House that won the vote to put mental health at equal esteem; it was not the other House, although the Minister, Norman Lamb, did help. It was an amendment by the noble Baroness, Lady Hollins, that won, although I had to call it because the noble Baroness was not here at the time.
I thank all noble Lords again; I am grateful that they all joined in this debate. It contained lots of ideas, but the key thing that came out was the need to make community and primary care stronger. The second thing was the solution to social care: it is funding, whichever way we go. The other thing was data. By the way, as the noble Lord, Lord Allan, was speaking, I asked ChatGPT: “How can data help healthcare?” It produced immediately a 700-word, six-point response; I might send it to the noble Lord.