National Health Service: 75th Anniversary

Baroness Walmsley Excerpts

Thursday 30th November 2023 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, I congratulate the noble Lord, Lord Hunt of Kings Heath, on his excellent introductory speech. He hit all the nails very firmly on the head.

As the NHS reaches its 75th year, it is a very different and much larger beast than when it started out. The challenges are not just greater but different. On the upside, to a great extent we have conquered infectious diseases through vaccination and sanitation. Because of the success of medical science, our population is ageing, leading to greater demand for healthcare. On the other hand, we have a high level of health inequality and poverty, and a food system that does not provide a healthy diet for many people. Preventable diseases are now the greatest cause of illness and death. In 1948, people walked everywhere; many did manual labour, so obesity was rare; they ate seasonally and cooked their meals at home, and ultra-processed foods did not exist. But the air was not necessarily cleaner, because we burned coal to heat our homes. Today, we lead a very different life.

So, post-Covid, the NHS has five major challenges. There is the state of social care, causing too many people to enter hospital and stay there for too long. Linked to that, there is a crisis in ambulance service response times and A&E waiting times, causing excess deaths and harm. Many diseases, including cancer, are being diagnosed far later than they could be, leading to poor outcomes. Long waiting lists for urgent and elective care are leading to damage to the economy as people cannot work while they wait. There is too little preventive work to help people lead healthier lives.

The Government’s response is a focus on increasing the front-line workforce while ignoring the poor communication and system planning in the service. While we certainly need to train and retain more health professionals, especially in deprived areas, they are not the only people the workforce plan should be focusing on. We need system planners and communications experts. The money available for the NHS to tackle these problems is not infinite, which means we need greater productivity.

Nobel laureate Paul Krugman said:

“Productivity isn’t everything, but in the long run, it is almost everything”.

A crude definition of productivity is the ratio of inputs to outputs. Some think this is all about individuals working harder, but NHS staff are all already working extremely hard. It is not about working harder but working smarter. It is about improving outcomes. It is also not just about national initiatives. There is bound to be poor buy-in for national initiatives when staff on the ground often have a better idea of what could be done better. That is not to say there is no room for national initiatives, but they do not need to be designed by McKinsey.

There are problems with measuring real productivity in the NHS: how to adjust for the mix and quality of outputs and recognising the difference between outputs and outcomes. The NHS produces a wide variety of outputs. GP appointments are not the same as hip replacements, but the service has quite sophisticated statistical ways of dealing with this. It is harder to adjust for quality. Doing two knee replacements rather than one looks productive, but not if the second was needed only because the first was botched; and especially, as in the case of a lady I know, if the patient has to see the consultant three times before he will accept that there is something wrong. Then we must ask, is the outcome better as a result of the NHS having done something? The lesson here is that it is productive to listen to patients. Unfortunately, the NHS has cut back on patient-reported outcome measures, which are a valuable way to assess outcomes. My first question to the Minister is: are there plans to reinstate or replace PROMs?

A recent internal paper about productivity said that NHSE is

“very good at generating ideas”

for efficiency initiatives but does not have clear processes to evaluate them. It added:

“The overall volume of initiatives means it is very likely that the system is overwhelmed, which means that initiatives are not as effective as they could be. Moreover, a lot of the initiatives we are taking forward lack the buy-in from front-line staff that is needed to make changes stick”.


The system and infrastructures that support waiting list management include IT and tools for proactive patient tracking, as well as the processes that staff follow to efficiently and accurately co-ordinate pathways for patients on waiting lists. Millions of hours of clinicians’ time are wasted due to inadequate IT systems. A recent BMA report found that four in five doctors believe that improving IT infrastructure and digital technology would help to tackle backlogs. Can the Minister therefore say whether systems analysts and IT and AI specialists are included in the workforce plan, as well as medical professionals? We did not just win the Battle of Britain using pilots.

Sadly, there are too many examples of the skills of our health professionals being wasted because of inefficient systems planning and poor communications. A recent example concerns former BBC journalist Rory Cellan-Jones, who suffered a broken elbow and facial bruising following a fall. He spent two unnecessary days in hospital and calculated that 90% of the staff time spent on his case could have been avoided with better planning and communications. It was eight days after his accident before he received appropriate treatment. It was not just a question of communication between staff, but communication with him. He says in his blog:

“Getting information about one’s treatment seems like an obstacle race where the system is always one step ahead. … But communication between medical staff within and between hospitals also appears hopelessly inadequate, with the gulf between doctors and nurses particularly acute. I also sense that, in some cases, new computer systems are slowing not speeding information through the system. On Saturday morning, as we waited in the surgical assessment unit, four nurses gathered around a computer screen while a fifth explained … all the steps needed to check-in a patient and get them into a bed. It took about 20 minutes and appeared to be akin to mastering some complex video game”.


It also took four hours to get the paperwork for his discharge.

My Lords, I have experienced a similar situation and it grieves me to see our skilled professionals not being used in the most cost-effective way. What are the Government planning to do about this?