NHS: Community Pharmacies

Baroness Pitkeathley Excerpts

Tuesday 6th December 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, I do not recognise the figure of 7.4%. The actual reduction is 4% next year and 3.4% the following year. I echo my noble friend’s comments and recognise the huge importance of community pharmacy. If we look forward 10 years, we will see a much greater role for community pharmacy within the NHS in supplying many of the services that are currently supplied by more conventional NHS services.

[Baroness Pitkeathley (Lab)]

My Lords, the Minister mentioned clinical skills. Does he agree that in rural areas in particular, community pharmacies play a role much wider than their clinical function in giving advice, information and sign-posting to patients and their families? Does he agree that that is a very important part of their function that should continue?

Social Care

Baroness Pitkeathley Excerpts

Thursday 1st December 2016 Lords Chamber

Moved by

[Baroness Pitkeathley]

That this House takes note of the challenges in the current system of social care and of proposals for reviewing it and for longer-term reform of the system.

[Baroness Pitkeathley (Lab)]

My Lords, here we are again. This is not the first time I have led a debate on social care in your Lordships’ House and I have been wont to call those who join me the usual suspects, because we are the relatively small band who bang on about this subject whenever we get the opportunity. There are new faces as well as old ones here today. It is particularly welcome that the noble Baroness, Lady Cavendish, has chosen this debate for her maiden speech, to which we all look forward.

I have to tell your Lordships that it makes pretty depressing reading to go back to the other debates on social care in which many of us have participated, because the problems remain the same and so little progress seems to have been made. If I felt that before all the other debates—in nearly 20 years in your Lordships’ House, I have rather lost count of the number of times I have focused on this—how much more I feel it this time, when endless reports and newspaper articles are telling us all how bad it is. Your Lordships will be all too familiar with some of the headlines of recent weeks. One said that,

“social care is at a tipping point”,

another that it was “Slow, patchy, cruel” and that social care funding is “not fit for purpose”. Others said that the bed-blocking crisis hit a new high and that local authorities,

“join NHS chiefs in call for extra … funds”.

It may surprise your Lordships to know that I have managed to find some comfort in these terrible analyses, because perhaps they show that at long last there is agreement across all areas about what the problems are. That will be evident in the briefings which your Lordships have received for this debate. It is not as though we have not agreed before, but perhaps not so strongly and not across all areas. When even the chief executive of the NHS, not to mention the chair of the Health Select Committee, and two former Secretaries of State say that if there is any extra money it should be put into social care, maybe we are at last ready to address the issues.

Am I being too hopeful? Perhaps. Certainly, the announcements we were hoping for in the Autumn Statement provided no comfort by their total lack of appearance or even mention. I bow to no one in my desire to have better broadband in rural Herefordshire but, really, can we get our priorities straight? How the Chancellor could ignore the pleas from all sides is beyond me. His decision has been met with incredulity and dismay and called shameful. Nevertheless, I am determined to spend less time today on the problems of social care, which are well known to your Lordships anyway, and more on what the possible options are.

Let me summarise the problems and leave others to elaborate. There is a shortfall in social care funding of about £2.5 billion between what is available and what is required. Four out of five councils do not have enough provision, especially for care at home, and at least 1 million people are going without the care that they desperately need. Much more stress is falling on family carers, who increasingly find it difficult to cope. The results of these shortfalls are all too apparent: too many people end up in acute and very expensive hospital care in hospitals which are already bursting at the seams, even before winter pressures begin to bite.

The situation is bad for everyone. It is bad for councils, which will face legal challenges if they are unable to meet the obligations placed on them by the very welcome Care Act; it is bad for the NHS, as hospitals fill with people who could and should be treated at home; it is bad for care homes that increasingly find it difficult to balance the books, with the resulting threats to the quality of care which recent TV programmes have illustrated; it is bad for family carers. In short, it is bad for anyone who cannot afford to pay for their own care. Even if you are a self-funder, it is bad for you because you have to contribute to underfunded local authority places if you are in a care home. So much for the so-called society “which works for everyone”.

I could go on with endless examples of the bad but I will not. I turn instead to offer options, in the hope that the culture in which we operate is finally changing enough to encourage bold and courageous action. They say that humans and cultures never change unless we are forced to do so. If that is the case, we are forced to do this now before the whole system is not just at tipping point and in crisis, but in danger of breaking down completely. I should say here that I always worry about the danger of too much criticism sapping the morale of the dedicated staff who work in social care and do their best. They are usually paid at the very lowest levels. We owe it to them as much as to the frail, old and disabled to think boldly.

We must first tackle the different methods of funding health and social care, which have been so difficult to overcome and such a barrier to the co-ordination and integration of health and care services. In 1948 when the system was established, men died on average at the age of 66, one year after retirement, and women at about 68. There was no need for the type and range of care we now need. It did not matter so much that while health was free at the point of delivery social care was always means-tested, because you were not going to need very much social care. Social care has been paying the penalty ever since for those decisions, which at the time they were made were perfectly logical. What we need now is a decision of the level and quality that our forebears made then in relation to the NHS. But this time it must be about reshaping health and social care around today’s needs, not those of the population of post-war Britain.

Various attempts have been made and we all remember them: the royal commission, the Wanless review, the Dilnot review, the King’s Fund commission on the future of health and social care and the Barker commission—but no government response has been sufficient. It is evident that what is really needed is a long-term, cross-party approach which takes an open and honest look at the system and, above all, is open and honest with current and potential care recipients about what they can expect.

I think we are now at a crossroads and can make one of two decisions. We can go on as we are, muddling along, trying to do more with less, managing demand by just not meeting it. That is how we are managing demand: we are just not meeting it. I remind your Lordships that, of the more than 1 million people who it is estimated are not receiving care, most have already been assessed as having high-level needs, because helping those with moderate needs is already a thing of the past in most areas. We can keep promoting independence—that is always a good thing—we can keep trying to get individuals to manage their own care better and, above all, we can keep trying to integrate the budgets for health and social care. There are some excellent examples of integrated care at local level which, no doubt, noble Lords will illustrate, but the overall picture is patchy and still too cautious and too hedged about with suspicion and lack of willingness to give up power over budgets, still less to transfer it to other professionals. A single pooled budget for the health and social care needs of a whole population would enable NHS and social care providers to agree the very best use of the public pound and to focus on services which reduce the need for long-term care.

I am sorry to go down memory lane, but I have been talking about this, as have many other people, for almost 40 years—it is probably over 40 years, in fact. My first book was published in 1978. It was about hospital discharge for older people. Funnily enough, it showed that proper co-ordinated care can happen only if there is a single budget in the control of those who provide the services, free from political control and including the contribution of the private and voluntary sectors too.

If we are going to go on with the current system, if we are going to go on trying to muddle along, then I must make a plea for honesty. No Government—and I include my Government in that—have ever made it clear to the public that responsibility for paying for care and for arranging it rests with individuals and their families and that public funding is available only for those with the least money and the highest needs. Most people are aware that NHS care is generally free at the point of use, but their understanding about social care is far less clear, and people therefore have inappropriate expectations. If I had a pound for every carer who has said to me, “My mum has paid taxes all her life, and I can’t understand why her house has to be sold or all her savings used to pay for her care”, I would be a millionaire. That carer is a perfect example of a person who is just about managing, caring for her mother and probably teenage children too, trying to balance paid work with caring responsibilities and so on.

As we are not transparent, no one ever prepares or plans for care, and they have to scrabble to arrange and pay for it at a time when they are anyway distressed by the very need for it. If they are not prepared to reform the system, the Government must surely be prepared to promote clearer public understanding of how the system works and what people can expect and, more importantly, what they cannot. People plan ahead for pensions, and it is possible they could similarly plan ahead for care, but only if they know they have to.

However, it will not surprise noble Lords to know that this sticking-plaster solution is not my preferred option. I believe we must embark on long-term reform of the system because this problem is not going to go away; it is only going to get worse. All international evidence shows that spending on health and social care rises inexorably as the population grows and ages. The question is not whether these costs will arise, but how they will be met. Will they be met by the public purse or by private individuals? We can talk for ever about achieving more with less and delivering better value, but that will never release resources of the scale required to meet the widening funding gap.

Every independent review of the past 20 years has recommended that in future funding of social care, as well as healthcare, should come from public, not private, finance. The needs of individuals cannot be divided up neatly into health or social care needs, as all those of us who over many years have tried to fathom the difference between a health bath and a social care bath have long acknowledged, and now is the time for us as a society to acknowledge that the funding cannot be neatly divided either.

We must embark on a frank and open debate about how to fund health and social care on a sustainable basis into the future and remind everyone that such a debate cannot be settled in a single Parliament, so we need to secure cross-party consensus on shared principles to guide that reform. We have enough research and excellent material to enable us to do so; we just need the will to do it. We know all the questions about social care, so let us not embark on any more questions about what social care needs. What we need now is answers.

To those who say that this is not the time to do this with public finances in such disarray and with so many other problems, which we have just been hearing about in the previous debate, I remind your Lordships that our forebears tackled reform in the middle of a world war when the country was pretty well bankrupt and not the fifth-richest nation on earth, which we keep being reminded that we are. The Wanless review called for this debate 10 years ago. It has never been more necessary, and it is now even more urgent. I beg to move.

--- Later in debate ---

[Baroness Pitkeathley]

My Lords, we have had an excellent debate and I thank all noble Lords who have taken part, especially the noble Baroness, Lady Cavendish, for her thoughtful speech which makes us eager to hear more from her. The topics covered today have been as wide-ranging as the issue itself but there has been agreement about the crisis which exists, if not yet on how to address it.

I did not of course expect the Minister to announce from the Dispatch Box the great public debate that I have called for today. Many others have called today for such a debate and it is of course way above his pay grade—but that does not mean that I resile one iota from the calls for that debate. We must have it; it is inevitable and it would be better to have it sooner than later—before the system really does collapse, as many people have warned us it will.

The Minister has had many suggestions and, with his usual courtesy and honesty, has certainly addressed some of them. I welcome his focus on the strategy and I certainly acknowledge the progress made, as he reminded us, with some STPs. However, a couple of examples that I have had remind us that the STPs should not be about just health and social care but should include carers and the voluntary sector. It is important to bear that point in mind as we go forward with the STPs.

The emphasis has been on the interdependence of the health and social care services, as well as on the needs of users, carers and care staff. I get the impression that the time is right, and I think that the Minister has confirmed this. The people at the top—even, dare I say it, at No. 10—have realised that something must be done. If you have a philosophy which says that the Government must work for all and that you must help people who are “just about managing”, or even the “not managing at all” as the noble Lord, Lord Warner, reminded us, I hardly think that you can avoid addressing this issue. If that is the case and there is agreement that something must be done, I hope that this debate can be required reading. Readers will find calls for more resources but I do not want that to frighten them off, because they will also find in this debate a wealth of practical and deliverable suggestions on how to address these issues. So although I am a bit depressed, I am not totally depressed. Like the Minister, I am not without hope and I certainly hope that by the next time the usual suspects meet here to discuss this, we will have made some more progress. I beg to move.

Motion agreed.

Adult Social Care

Baroness Pitkeathley Excerpts

Tuesday 15th November 2016 Lords Chamber

Asked by

[Baroness Pitkeathley]

To ask Her Majesty’s Government what is their response to the warning by the Care Quality Commission in their State of Care report, published in October, that adult social care is approaching “tipping point”.

[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

My Lords, we welcome the State of Care report. We know there are serious pressures on the care system. That is why we are giving local authorities access to up to £3.5 billion in new support for social care by 2019-20 so they can increase social care spending in real terms by the end of this Parliament.

[Baroness Pitkeathley (Lab)]

I thank the Minister for his usual courteous reply, but I think he knows that the funding he has announced there for the better care fund is both too little and too late. Does he agree that there have never been so many challenges for the social care system? There is terrible pressure on the NHS and on caring families, and many people have no care at all at home, however great their needs. Does he further agree that there has never been so much consensus about what needs to be done? Across all professions and political divides, we hear that what is needed is more money, and more money now. I am well aware that asking for commitments in the Autumn Statement is above the Minister’s pay grade, but could he please assure the House that he and his colleagues are stressing the urgency of this matter to the Chancellor of the Exchequer and asking him to make more funding for social care an urgent priority?

[Lord Prior of Brampton]

My Lords, I think most people in the health and care system, whether it is Simon Stevens, the chief executive of the NHS, or the Secretary of State, realise how serious pressures are in social care. There is no question about that. The State of Care report from the CQC supports that view. That is why we are putting in more money towards the end of this Parliament. It is back-end loaded—I accept that—but on the other hand the £3.8 billion that went into the NHS this year is front-end loaded. I think everyone agrees that the only way out of the difficulties we are in is for health and social care to work much more closely together.

NHS: Cancer Patients

Baroness Pitkeathley Excerpts

Wednesday 9th November 2016 Lords Chamber

[Lord Prior of Brampton]

There are lies, damned lies and cancer statistics. It is extremely difficult to make comparisons on survival rates with other countries. There is evidence that we are behind the best in Europe on five-year survival rates. There is also considerable evidence that we are making good progress—but, of course, other countries are making good progress at the same time. If we implement the cancer task force recommendations, it is estimated that we will save an extra 30,000 people’s lives per annum. We have a very ambitious programme to improve cancer outcomes, but I accept that we are starting from some way back from the best performance in Europe.

[Baroness Pitkeathley (Lab)]

My Lords, does the Minister accept that early diagnosis depends on patients or potential patients recognising the symptoms? Notwithstanding the pressure on services, are the Government continuing to encourage patients to recognise potential cancer symptoms?

NHS: Primary and Community Services

Baroness Pitkeathley Excerpts

Monday 7th November 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, delayed and inappropriate discharges are clearly a huge issue for the whole health and care system. Again, this is something the STPs are designed to address. The five-year forward view is explicit in saying that there are 5.5 million carers in England and their continuation goes to the very sustainability of the NHS. The importance of care is not in dispute. The Care Act, which the noble Baroness’s party and mine put through in the last Government, recognised that so as to give them parity of esteem with those they care for. There is no question but that better communication with carers would go a long way to improving the problems we have with inappropriate discharges.

[Baroness Pitkeathley (Lab)]

My Lords, the Minister has acknowledged that discharge from hospital is an important time for carers. You can literally become a carer overnight when your relative is discharged without warning. The carers strategy is currently being refreshed. Would the Minister consider an input into the carers strategy that meant it was incumbent on the National Health Service to consult carers and get their agreement before discharges are made?

[Lord Prior of Brampton]

My Lords, I am not sure we could go so far as to say that one should always have their agreement—sometimes, discharges from hospital are incredibly complex and difficult—but there is no doubt, arising from the Carers UK report, that where there is proper communication with carers, the discharge procedure is much better for everyone, from the point of view of the carer, the patient and the hospital. If proper arrangements are not put in place, delays arise long after the patient should have been discharged home. It could be to do, for example, with a care package or altering the patient’s home.

NHS: Health and Social Care Act 2012

Baroness Pitkeathley Excerpts

Thursday 8th September 2016 Lords Chamber

[Baroness Pitkeathley (Lab)]

My Lords, I too thank my noble friend for bringing forward this important debate, and I congratulate him on getting the time.

I always thought that the best thing about the Health and Social Care Act was its title. I was not alone in thinking that. It gave us hope that, at long last, the issue of social care would be put on a par with health in the delivery of services. Over the many years that I have been concerned with these issues, I have lost track of the number of times I have heard people say, “You cannot run a patient-focused NHS without regard to the whole patient experience”, which of course includes their experience of social care. Admission, discharge, post-discharge and follow-up are all inextricably entwined, especially for those with long-term conditions. So we had high hopes from that title and were repeatedly assured that the Government understood the importance of social care, that the new arrangements would ensure collaboration and co-operation between health and social care providers, and that adequate funding would be provided to local authorities to ensure that their obligations could be met.

Like many noble Lords, I had major misgivings about the disruption that the Health and Social Care Bill would cause and the money it would cost—especially as the promise had been made that there would be no top-down reorganisation of the NHS, as my noble friend Lord Rea has reminded us. The Bill appeared to presage not just a top-down but a bottom-up reorganisation. However, the idea of better integration certainly appealed to me. In 40 years of working in this area, I have noticed two things repeatedly. First, there is the absolute inability of any patient of any kind to understand the lack of integration, or sometimes the lack of communication, between the two services. Patients will always say, “But I don’t understand—why are they so different? Why don’t they talk to each other?”. Secondly, there is the repeated response of any professional involved in delivering patient care that more integration and co-operation is not only desirable but essential. So the test which I now apply to the Act is how we are doing on integration.

The Government were warned at the time that their proposals for structural reform were going too far, too fast. So far as social care is concerned, it is perhaps not fast and far enough. We have seen a social care system which is neither well funded nor sustainable and which, as a consequence, contributes to the problems in the NHS that so many noble Lords have mentioned. Two weeks ago, I visited an elderly friend in an acute ward. She had been ready for discharge for two full weeks but was unable to be discharged because of the lack of social care provision. Eight more people in the ward she occupied were in the same position.

A well-funded and sustainable social care system underpins a sustainable NHS. Delayed discharge is possibly the most pressing concern for the NHS and the Department of Health at present. It is inextricably linked to rising social care demand, caused by the greatest social and political challenge of our time: the ageing population. That ageing population is of course also a triumph and we should celebrate it, but we cannot ignore the strain that it puts on our provision of health and social care services. Social care is the largest area of spending at local level and has been hit hard by central government-enforced austerity. Meanwhile, demand for social care is of course rising; it is predicted to increase by 44% by 2030. More people are living longer with more complex, long-term conditions that require a higher level of expertise and intervention. The Nuffield Trust has estimated that by 2020, there will be a funding gap in adult social care of between £2 billion and £2.7 billion, despite the social care precept and the better care fund.

I hope the Minister will not use the better care fund and the precept as a panacea, a cover-all, for these difficulties because they are already inadequate and do not compensate for the 37,000 social care beds which will be lost before 2020 nor for the introduction of the national living wage.

The Health Select Committee conducted an inquiry into the impact of the spending review on health and social care, and the chair, Dr Sarah Wollaston, concluded:

“Historical cuts to social care funding have now exhausted the opportunities for significant further efficiencies in this area. Increasing numbers of people with genuine social care needs are no longer receiving the care they need because of a lack of funding. This not only causes considerable distress to these individuals and their families but results in additional costs to the NHS. We are concerned about the effect of additional funding streams for social care not arriving until later in the Parliament”.

Will the Minister say when additional funds will be achieved and when they will arrive, and will he give us his estimate of how they are going to cope with many of these problems? I remind him that ADASS calculates that the sector will need £1 billion per year just to allow it to stand still and that most local authorities say that they will have to spend the whole of their budgets on social care within five years or so.

I have been disappointed in my hopes for social care from the Act, but I have also been disappointed in my hopes for the strengthening of the patient voice which was promised. Local Healthwatch and local health and well-being board organisations have been patchy, as we warned the Government at the time that they would be, while the disempowerment of Healthwatch England by denying its independence and clipping its wings has not been an edifying spectacle.

As far as social care and integration is concerned, there are some excellent examples of good practice, as the Prime Minister acknowledged yesterday, but they are far too few and, as she also said, further review is necessary. I was very pleased to hear her say that at PMQs yesterday. I hope the Minister, who is so knowledgeable on this topic, will assure us that this review will take place soon, as it could not be more urgent.

NHS: Unsafe Hospital Discharges

Baroness Pitkeathley Excerpts

Wednesday 15th June 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, there are millions of interactions between patients and consultants and doctors every day of the year, and there will be some mistakes. We cannot draw conclusions from one or two desperate situations. In so far as they reveal systemic problems, it is valid to draw attention to individual cases of this kind, and there are some systemic issues lying behind the PHSO’s report. In particular, it states:

“We are aware that structural and systemic barriers to effective discharge planning are long standing and cannot be fixed overnight … health and social care … have historically operated in silos”.

That is the issue on which we should be focusing.

[Baroness Pitkeathley (Lab)]

My Lords, I ask often in this House and elsewhere about co-operation between health and social care. Does the Minister agree that one thing we lack is a cohort of people, be they nurses or paid professional carers, who can work across health and social care in hospital and follow patients into the community? Will the Minister update the House on what is happening to encourage that kind of cohort?

Learning Disabilities: Transforming Care

Baroness Pitkeathley Excerpts

Thursday 9th June 2016 Lords Chamber

[Lord Prior of Brampton]

All the transforming care partnerships will comprise both CCGs and local authorities, so all the experiences learned by local authorities should be paid into the process.

[Baroness Pitkeathley (Lab)]

My Lords, does the Minister agree that when such in-patients leave in-patient care, much of the responsibility for looking after them actually lies with their families? As this is Carers Week, would the Minister update the House on the Government’s attitude to this with the revision of the carers’ strategy?

[Lord Prior of Brampton]

I think we have a direct Question on carers next week. We are absolutely committed to supporting carers. Where people who have been in hospital for more than five years are discharged back into the community, as it were, the CCGs will provide them with a dowry to cover their costs. It will be very clear that the funding of those patients will stay with the CCGs.

NHS: Hospital Overcrowding

Baroness Pitkeathley Excerpts

Tuesday 15th March 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, a lot of what was said by the person, whose name I cannot remember, to whom the noble Lord refers, was absolutely right, but when he said that there were no more efficiencies to be gained he was completely wrong. We can still achieve huge efficiencies throughout the whole healthcare system, in the context that the NHS is one of the most efficient systems in the world, but it can be better. It would be completely wrong to say that no more efficiencies can be achieved.

[Baroness Pitkeathley (Lab)]

My Lords—

[Lord Vinson (Con)]

My Lords—

--- Later in debate ---

[The Lord Privy Seal (Baroness Stowell of Beeston) (Con)]

My Lords, it is the turn of the Labour Benches. While I am on my feet, I remind noble Lords that we should not be reading out questions at Question Time.

[Baroness Pitkeathley]

My Lords, will the Minister agree that there is bound to be overcrowding in hospitals if we have a point of entry without any guaranteed point of exit? Therefore, unless social care is adequately funded and organised, we will always have this problem of overcrowding, particularly where old people are concerned. I would be very glad if he did not refer me to the better care fund as the answer to this, because it is already oversubscribed many times.

[Lord Prior of Brampton]

My Lords, I will not refer to the better care fund, but I agree with the noble Baroness that flow through a hospital is essential. Blockages at the end of the flow can cause problems further down the line in A&E departments. I entirely agree with the noble Baroness’s analysis, but it is more complex than just looking at social care. Two-thirds of the delayed transfers of care are caused internally within the NHS, compared with only one-third by social care, but the noble Baroness makes a very strong point.

National Health Service

Baroness Pitkeathley Excerpts

Thursday 14th January 2016 Lords Chamber

[Baroness Pitkeathley (Lab)]

My Lords, I am indebted to my noble friend Lord Turnberg not only for securing this debate but for his long-term contribution to health debates and the development of health policy in your Lordships’ House. Like him and many noble Lords speaking today, I am greatly committed to the NHS. In fact, I owe my life to it. No price can ever be put on that, and no acknowledgment is enough.

Many statistics will be traded here today but I am not going to engage in that. I shall focus on the wording of the debate so far as future demands are concerned and offer my thoughts on what the NHS needs in order to be the institution we know, love and admire into the next century.

In my view, there are two essentials. First, to have a viable health service you have to have a social care service which works. We are all familiar with the reasons why the post-war settlement set up different systems of care: men died at 66—one year after retirement—and women at 68 or 69, so you did not need much social care in those days. Now, with our ageing population, the contrast between a health service free at the point of use and a social care system which is means-tested and publicly funded only for those with heavy needs results in a lottery, so the type of ailment you have will determine the financial support you get to cope with its effects. There is no equity. Moreover, efficiency is hampered by a lack of integration in organisation as health and social care are separately commissioned. Look at the 3,000 hospital beds today occupied by people fit to leave but stuck there because funding or assessment has not been resolved. The economic cost of this is huge but to it must be added the cost of the human misery caused by this situation.

We simply must move to a single, ring-fenced budget for health and social care which is commissioned in one place and within which entitlements are understood. We hear constantly that health and social care are becoming better integrated. In the 18 years I have been in your Lordships’ House, I have lost track of the number of times I have heard that assurance from Ministers on all sides of the political divide, but progress is piecemeal at best. We have to hope that somewhere, sometime and soon we will have a Government with enough vision and courage to disregard the five-year focus of any Government and propose a proper reassessment of the post-war settlement to reflect the current and future needs of our ageing nation. It can be done with vision and commitment, as my noble friend has shown us in Salford.

The second thing the health service needs—here I echo the noble Lord, Lord Fowler—is to focus not so much on curing illnesses but on the prevention of illnesses. Statistics are legion about the illnesses which are debilitating to the individual and expensive to the NHS, and the obvious way of tackling them is to prevent them arising in the first place—for instance, diabetes, so associated with obesity; strokes, so associated with high blood pressure; and lung diseases, so associated with smoking and lack of exercise. Yet time and again we hear that nowadays prevention programmes run statutorily or by the voluntary sector are being cut because they are long-term investments and may not pay off, so to speak, for as much as 10 or even 20 years, so they make easy targets. Does the Minister agree that this is short-sighted? We are at a point where only far-sighted, perhaps controversial, but courageous actions will preserve for the long term our much-loved and much-admired NHS.