Future of Health and Care

Baroness Thornton Excerpts

Tuesday 23rd February 2021 Lords Chamber

[Baroness Thornton (Lab) [V]]

My Lords, I thank the Minister and declare my interests as a former member of a CCG and a non-executive director of a foundation trust.

The Lords Labour health team—myself and my noble friends Lady Wheeler and Lord Hunt—are veterans of the infamous Lansley Bill, which became the Health and Social Care Act 2012. Many noble Lords will take part in the new legislation—including, of course, those on the Lib Dem Benches, who supported the Lansley Bill. I hope that they have come to their senses since then.

We cannot sweep under the carpet, as the Secretary of State and the Minister would have us do, the fact that many of us warned that the huge bureaucracies and implementation costs of something like £3 billion would be a terrible waste of public money and time. They resulted in a loss of initiatives and innovations that lies at the Minister’s door. Some indication of lessons learned would be welcome.

We are in the middle of the biggest public health crisis our NHS has ever faced. Staff on the front line are exhausted and underpaid. The Royal College of Nursing says that the NHS is on its knees. Primary care and CCG staff are vaccinating and will be doing so for months ahead. Today, we learn that 224,000 people have been waiting more than 12 months for treatment. The Secretary of State and the Government think that now is the right moment for a structural reorganisation of the NHS. It might be significant that, in the Statement, I cannot find a single explanation of how patients will benefit from this reorganisation. It is all about systems.

Apart from the timing, some very serious matters need to be addressed. This is a Conservative NHS plan, and it shows. Without the money, none of this is worth discussing seriously. Without a workforce plan funded by that money, it will not work. This Bill should not go ahead in its current breadth until the solutions for social care and public health are also set out. Although reform of the Mental Health Act is welcome, it also needs to fit into the wider solution that is missing around social care.

Why does the White Paper not include an option simply to delete Part 3 of the existing Act, thus abolishing the market and competition regimes that created the burdensome bureaucracies and which, it must be said, many CCGs and ICSs have worked hard to get round in recent times? Let us take some time to work out the rest, bring forward the promised social care reforms, let our exhausted NHS recover and have a system co-created with local government.

I suspect that the need to move powers to the centre is a poisoned chalice. Is the Minister proposing simply to dump the Lansley structures and bring back the situation where the Secretary of State has the power of direction over all and any parts of the system? Although I welcome the place-based commitment, it is woefully undefined. This plan ought to be co-owned and co-developed with local government nationally as well as locally, with real parity of esteem. Far more is needed to remove barriers, but the biggest local barrier now is the absence of any solution for social care and public health.

Looking at the NHS’s history, we should be sceptical of structural reform necessarily leading to changes in care delivery that make services more integrated and benefit patients. We know from Wales, Scotland and Northern Ireland that integrated care systems have not brought about integrated care. It is necessary to remove system barriers but not sufficient. The bigger challenges lie around culture and vested interests, which are not even mentioned in this White Paper. It is all far too complicated, with health and well-being boards and HealthWatch still in place as well as the proposed new structures. It needs a clear explanation of who controls the money. Can you have two boards at the same time and call it integrated, and be sure where the accountability sits and whether good governance can be assured?

There is little about how decisions are made on who sits on these boards. Is it proposed to bring back independent appointments commissions to guarantee the diversity required? Will staff representatives and patients have a seat where it matters? Surely there can be only one body with the power to set the local strategy and sign off the plans that bring the money. This proposal seems to have many bodies, meaning that governance and accountability are at risk. Having providers, and even independent providers, with a place in the decision-making about resource allocation is clearly unacceptable. If there are to be some contracts awarded by competition, there must be clear rules about who is entitled to compete. These organisations and companies must pay their taxes, for instance, and must offer fair and comparable terms and conditions to their workforce. For example, we know that social enterprises totally fulfil those conditions, but one must ask why we need competitive tendering when you can hand out contracts to chums from the stables, the golf course, and the pub, as we have seen in the last year.

The White Paper is silent on the future of foundation trusts, silent on the role of governors, silent on a whole range of potentially competing governance issues which will have to be resolved. How much acute and tertiary care can be brought into locality-based structures? Integration of primary, community and social care is clear, but, as everyone knows, the acute side is far more complex and a single solution, as proposed in this White Paper, almost certainly will not work. The big players such as teaching hospitals do not fit into any single locality, or even single ICS, but are vital players. Will there be extra layers of governance above the ICS, which is not defined at all?

We will of course study the legislation carefully when it is published, but the test of reorganisation is whether it benefits patients and communities, brings down waiting lists and times, widens access, especially for mental health care, drives up cancer survival rates and improves the population’s health.

[Baroness Brinton (LD) [V]]

I am grateful to the Minister for the short-notice briefing just as we were rising for recess.

If you had said to most people in the health and social care sector three weeks ago that the Secretary of State for Health and Social Care was announcing a new White Paper, virtually everyone would have assumed that it was the extremely long overdue White Paper on social care, promised by the Prime Minister in his party’s manifesto in the 2019 general election and repeatedly further promised at the Dispatch Box over the last 14 months. This Statement refers to it appearing at some point later in the year.

Instead, we have a comprehensive White Paper that focuses, despite the references to care, on the NHS and health systems, undoing some but not all of the 2012 Lansley reforms. This White Paper talks grandly of integrated systems, but you cannot integrate systems if one of the key parties is on its knees as a result of appalling neglect for many years. We agree that our clinicians, managers and associated health and social care staff have great ambitions for moving our health and care structures into the 21st century, and we compliment them, and Ministers, on their ambition, but we have been here before. A decade ago, the Government announced and legislated for a Dilnot-style cost model for social care, which, unfortunately, was later scrapped. We went from a point where all three main political parties were in agreement, but, sadly, the Conservatives withdraw from that agreement. As with manifesto promises on the care sector over the last three general elections, when will the Government start the long-promised cross-party talks to find a solution for the care sector? We remain ready and waiting.

The Statement makes the point that the pandemic has brought the structural difficulties in the care sector into sharp relief. That much is true. With more than 25,000 care home deaths, 10,000 of which have occurred since the lockdown started in January, what will it take for the Prime Minister to make good on his promise to fix social care? Why did it take weeks longer to arrange for residents and staff in care homes to get testing, whereas the NHS had reliable access as soon as it was available? Worse, the care sector’s experience of the Department of Health and Social Care taking its orders of PPE out of lorries and diverting them to protect the NHS first—which happened—and the NHS discharging Covid patients into care homes, while reassuring care staff that it was not doing that, has undoubtedly damaged trust. I do not deny that there has been a really strong attempt to get people to work cross-department, but this sort of behaviour has really not helped.

The Statement talks about making Ministers accountable again. A good step would be for the Secretary of State to come to Parliament and explain why he did not publish PPE and other contracts within the appropriate timeframe. There are concerns, too, about cronyism and possibly even corruption. So I say to Ministers: beware of what you wish for.

A further problem of the White Paper in front of us is the need to undo some of the perverse bureaucracies and expenses created by the 2012 reforms. The “internal market” was one such. I cannot see the logic of having a CCG of GPs overriding NICE and a hospital team on a medication pathway because it wants to spend the money elsewhere. The Minister told me that there will be changes and that there will be some representation from trusts, but, from what I hear, it is not enough to leave the clinicians who are expert in charge able to follow the advice of NICE.

The Statement also talks about the portrait of Sir Henry Willink, who published the 1944 White Paper from the Dispatch Box. But Sir William Beveridge’s report that led to that White Paper, and then to the post-war Labour Government’s creation of the NHS, had a clear structure. The five great evils that Beveridge, as a Liberal, set out could be tackled only by a cross- departmental approach, of which health was a vital component but not the sole driver.

When my grandfather was dean of St Mary’s Hospital Medical School, he always used to say that it took only 20 years for the NHS to move to a “national illness service”, as demand and costs in hospitals increased exponentially and any budget that was not for hospitals was squeezed. That is why, in the 2012 reforms, we in coalition wanted at least elements of public health moved to local government, where it could more effectively work with the other parts of the system fighting Beveridge’s five great evils and, through the health and well-being boards, be accountable at a local level. The examples of the excellent directors of public health during this pandemic have shown that it can and does work, despite the NHS finding it difficult to delegate to them. It is no surprise that inequality is one of the greatest predictors of serious Covid illness or death. Can the Minister reassure us that, whatever happens to public health, it will have its funding ring- fenced to tackle these inequalities?

Next week, we have the Budget, in which the Chancellor will have to face the highest levels of national debt since the Second World War. After the publication of his report, Beveridge expressed concern, saying that the Government should be bold:

“Now, when the war is abolishing landmarks of every kind, is the opportunity for using experience in a clear field. A revolutionary moment in the world’s history is a time for revolutions, not for patching.”


Now, too, is the time for such revolutions. This pandemic has left us with a health and social care system that needs not just reform but proper funding. Without it, integration and effective joint working will fail. Can the Minister assure us that there will be bold actions to ensure that any changes are fully funded? Without it, Atlee, Beveridge and Willink will be turning in their graves. Worse, these proposed reforms will fail the UK people, whether patients or just those living in their communities—the very people who need it most.