Health and Care Bill

Debate between Lord Bethell and Lord Warner

Lords Hansard - Part 1 & Committee stage
Wednesday 26th January 2022 Lords Chamber

[Lord Warner (CB)]

My Lords, briefly, I support these amendments, partly from my own experience as a director of social services and Children’s Commissioner, but also because of the points that the noble Lord, Lord Mawson, raised.

I have three key points from history. As a director of social services in the 1980s and 1990s, I offloaded my local authority family centres to the voluntary sector because a survey of parents suggested that they would not come to a service run by the organisation that was likely to take away their children. That was a perfectly rational position and we should listen to what people say about that.

Fast forward to 1999 and parenting orders under the Crime and Disorder Act. We find that compulsion brought parents to the party but, when they actually attended, they found—not so much men but women—that they were being treated and given skills that enabled them to manage children, largely teenage children, much better than they had been. It was a great shame that we used the criminal justice system to bring people to a parenting tuition experience that they should have been given many years before.

This is a final point from history. Michael Gove made me—this was madness on my part, as well as his—children’s commissioner for the failing Birmingham City Council children’s services. Ofsted report after Ofsted report had been telling them of their deficiencies. We found that the group they could not handle, for which they had no effective responses, was teenagers. If we are to make any progress in helping people to help the family unit, we need to address the support given to parents during the teenage years, because they are really struggling, particularly mums.

[Lord Bethell (Con)]

My Lords, I will briefly say that I am extremely optimistic about family hubs. They answer the challenge to solve the complexity around integration incredibly well. My noble friend Lord Farmer made the point that one cannot think of a better example of what integration looks like than family hubs. The noble Baroness, Lady Tyler, talked clearly and persuasively about the journey they have been on.

My noble friend has made the case for these amendments. Other noble Lords have made the case for updating the legislative framework. I ask the Minister to look carefully at what can be done to bring these laws up to date so that family hubs can thrive, as I believe they will.

Health and Care Bill

Debate between Lord Bethell and Lord Warner

Lords Hansard - Part 2 & Committee stage
Tuesday 11th January 2022 Lords Chamber

[Lord Warner (CB)]

My Lords, I will say a few words about specialised services on the basis of a committee that I chaired about five or six years ago at those services’ request. It followed the demise of strategic health authorities under the 2012 Act. The one thing that this committee demonstrated very clearly was that population was significant and that, if you ignored population, you were not likely to get good outcomes. There was no magic figure on population but it was of a size common in the territories of most of the SHAs. That is not to say that the SHAs did a crackingly good job, but they were the organisations with the size of population necessary for good commissioning of many of these specialised services.

The trouble was—and it is the same trouble mentioned by the noble Lords, Lord Lansley and Lord Sharkey—that if you have a regional system, by definition you give it some degree of control over its priorities. It follows almost as night follows day that different regions will take different views about the significance of specialised services in their particular region. We have struggled with this issue for many decades and not found it easy to come up with a solution.

You can go the whole hog and put it on NHS England, but that poses the problems that the noble Lord, Lord Sharkey, honestly owned up to: many of the people with these conditions are getting a range of services outside that specialised commissioning service. I came to the conclusion that you have to have something that is of the size of, or of a similar size to, the former SHAs, but you do need a role at the centre trying to ensure a level of consistency of approach in those larger areas. I think we are still fumbling our way towards the right mix of that and I cannot see that we will be able to put in this legislation a definitive answer to that particular set of conundrums.

While I am on my feet, I shall speak to Amendment 215, to which I have added my name. To some extent, I reinforce the seriousness of the situation that Ministers and the public face with the enormous backlog of patients awaiting treatment that the noble Baroness, Lady Wheeler, drew attention to. I refer the Committee’s attention to the excellent report by the National Audit Office published about six weeks ago. This report made it absolutely clear that in September 2021 there were nearly 6 million people on the waiting list for elective care and that one-third of these people had been waiting longer than the waiting standard of 18 weeks. Some 300,000 rather unlucky people had been waiting in pain and discomfort for more than a year. The NAO made it clear that even before Covid-19, many parts of the NHS were not meeting the waiting time standard and that about one in five cancer patients was not meeting the waiting standard for urgent referrals by GPs—that is a pre-Covid situation that has simply got worse as time has progressed.

I recognise that the Government have promised to provide an additional £8 billion between 2022-23 and 2024-25, some of which they expect the NHS to use to increase elective capacity by 2024-25 by 10% more than its pre-pandemic plans. I have to say, as a former Minister responsible for reducing waiting times and implementing the original 18-week maximum wait, that Ministers need to realise that announcing the extra money is the easy bit; putting in place a system for ensuring that the NHS leviathan actually uses the money for its intended purpose and can demonstrate delivery of the promised outcome is an entirely different matter. It took the Blair-Brown Governments from late 2004 to early 2008 to deliver the 18-week maximum wait and the cancer targets, using a lot of different tools in the ministerial toolbox.

There is not one simple solution to delivering these changes. The regimes that were implemented by those two Governments used a lot of extra money; a relentless, transparent measurement; and a great deal of clinical and political management pressure. They used expanded patient choice, so that patients could drive change, and I have to say to the noble Lord, Lord Davies of Brixton, that they also used the private healthcare system to increase diagnostic and surgical capacity by about 10% to 12%, but they did so at NHS prices. So, there is not a single solution; there are a lot of solutions that have to be applied and measured.

A critical factor in this is keeping everybody honest through transparent information about how progress is being made. If that is lacking, you are probably doomed to fail. The strength of Amendment 215 is that it puts in place a system for regular reporting of progress being made—or not being made, in some cases. It is important, as my own experience has shown, to know which parts of the country are doing well and which are not doing so well, so you can actually ensure that some action is taken on the slowest ships, as they say, in the convoy.

It should come as no surprise from what I have said that I strongly support Amendments 6 and 19 and do not support Amendment 21. I recognise, as we were discussing earlier this afternoon—time flies; I mean this evening—the whole issue of health outcomes and outcomes frameworks. Those are very important. However, at the end of the day, you cannot secure good outcomes without speedy access to clinical services. You do not get them. Waiting times of the length we currently have can lead only to poor outcomes. We must put in place systems that measure the progress being made in driving these waiting lists down. Given the seriousness of the situation, we need something about this in primary legislation to ensure that people across the country and the NHS are moving in the same direction in driving waiting times down.

[Lord Bethell (Con)]

My Lords, I want to say a brief word in support of the amendment on innovation in the name of the noble Baroness, Lady Thornton.

Having just been the Minister for Innovation, I can tell noble Lords that they could fill their entire diary travelling the country and seeing fantastic innovation in the NHS up and down the country. Noble Lords could fill their Zoom calls speaking to countries around the world that look to the NHS for some of the best innovation and partner with it on innovative programmes. However, that innovation is often extremely isolated and rarely spread evenly across the whole country. In fact, I often thought that my job title should have been not Minister for Innovation but Minister for Adoption because my role should have been to take the best that the NHS does and spread it across the country more evenly. That is the objective of the Government’s health policy at the moment: to see a much more even spread of best practice right across the country.

Although we cannot legislate for culture, we can give signals to the system about what we think is important. I therefore think that the noble Baroness, Lady Thornton, is on to something in suggesting this amendment. It should be given careful thought by the Minister.

NHS Funding Bill (Money Bill)

Debate between Lord Bethell and Lord Warner

3rd reading & 2nd reading & Committee negatived & 2nd reading (Hansard) & 2nd reading (Hansard): House of Lords & 3rd reading (Hansard) & 3rd reading (Hansard): House of Lords & Committee negatived (Hansard) & Committee negatived (Hansard): House of Lords
Wednesday 26th February 2020 Lords Chamber

[Lord Bethell]

My Lords, I join those who have paid tribute to the work of my noble friend Lady Blackwood, my predecessor at the Dispatch Box, who made an invaluable contribution to the Department of Health and Social Care and is very sorely missed. I also thank the noble Baroness, Lady Thornton, for offering to join my campaign team. It is an offer that I am very happy to accept.

I was warned by the Chief Whip not to say that this was a vintage House of Lords debate and the House of Lords at its best, because it is hackneyed—but it is true. This has been a terrific debate, very highly informed and very challenging. There have been an enormous number of challenges in this debate—far too many for me to get through all of them—but I will try my best. Forgive me if I rattle through things a little.

I reassure the House that the NHS is the top priority of the British people, as a number of noble Lords have rightly pointed out, and of this Government. I know that there may be cynicism about the long-term plan that is being discussed today and about the Bill. The numbers that have been put forward in the Bill came from the NHS itself. The Bill enshrines those numbers in law. It is not a gimmick, and it is not Swiss cheese, as one noble Lord put it.

[Lord Warner]

I think most of us thought that these numbers came from NHS England, not the wider NHS. Can the Minister clarify that?

[Lord Bethell]

I am happy to accept that clarification. The noble Lord is exactly right: the numbers are from NHS England and they apply in that way.

To go back to Swiss cheese, the Bill is an ironclad guarantee to protect NHS funding. We are giving the NHS the certainty it needs to invest now for the long term. I thank the noble Lord, Lord Hunt, who put his finger on it. He spoke about the culture of short-termism and rightly mentioned—as did other noble Lords—the excellent report of the noble Lord, Lord Patel, on long-term sustainability. The natural human instinct to mitigate and to hedge when finances and money are uncertain has been remarked on in this debate. It is an entirely human instinct. The Government want to remove that uncertainty and to send a really clear signal to the system. We want to remove any sense of political risk about finance, so that decision-makers in the health system can make the best possible plans without looking over their shoulders to the finance director. They can instead be brave and make the best decisions possible and, in that way, implement the long-term plan in the most efficient way possible.

Where I have a difference of opinion with the noble Lord, Lord Hunt, is in his scepticism that reducing demand for hospital care is not possible. This Government believe that prevention is better than cure. That is why we are placing huge emphasis on community services, primary care and supporting people to live in the community, which reduces the number of people looking for acute care. We are investing in GPs and in urgent care centres to ensure that people are treated in the right place and at the right time.

I will talk first about the Bill in its essence. A number of Peers, including the noble Lord, Lord Hunt, have remarked that it is not enough money. I remind noble Lords that the plan comes from NHS England and that the Bill does not limit the amount of funding that we put into the NHS. Instead, it sets out a budget that must be at least what we have committed to. I reassure the noble Baroness, Lady Brinton, that this is not a cap. That is laid out clearly in Clause 1, which states:

“In making an allotment to the health service in England for each financial year specified in the table, the Secretary of State must allot an amount that is at least the amount specified in relation to that financial year.”


I will now tackle a few points of detail. The noble Baroness, Lady Thornton, asked about transfers from capital to revenue. We have said that such transfers were a short-term measure and are being phased out. Furthermore, the Treasury operates strict conditions on transferring between capital and revenue budgets. This is not a blanket ban. Sometimes technical adjustments between capital and revenue are needed for operational reasons, but these are a temporary measure.

The noble Lords, Lord Hunt and Lord Warner, asked about trust debt. We totally recognise that the stock of debt has grown and in recent years has become a significant financial challenge. We are working with NHS England and NHS Improvement to agree a framework of bringing provider debt down to an affordable level. We look to establish a new financing framework for 2020-21 that complements the NHS long-term plan.

The noble Baroness, Lady Finlay, was 100% right to raise the challenge of health inequality. We were all chastened by the Marmot review, which told uncomfortable truths. We completely accept the right to a long life. This Government are not ducking the challenge of health inequality. In fact, when we talk about levelling up, what could be a more vivid and valued form of levelling up than health equality? That is why we have put so much emphasis on laying down concrete commitments to these financial numbers and laying out, to the best of our ability, a long-term plan for the NHS.

The noble Lord, Lord Warner, asked a marathon six questions, which I will not be able to answer in their entirety. I will just tackle the question of cash not being index-linked and numbered. The NHS budget, like many other departmental settlements, is always set out in cash terms. This is essentially to deliver certainty. Experience has taught us that every time inflation goes up or down, budgets need to be reopened and confusion reigns. Furthermore, we as a House should remember that we are proposing a floor, not a ceiling; this is the kind of clear reassurance that has been asked for by the system.

I reassure the noble Baroness, Lady Brinton, that additional spending on the NHS in England absolutely leads to an increase in funding for the devolved Administrations through the Barnett formula—£7 billion for the Scottish Government from 2019-20 to 2023-24; £4 billion for the Welsh Government; and £2.3 billion for the Northern Ireland Executive. We will undertake a spending review later this year and will publish multiyear Barnett-based block grants for the devolved Administrations shortly afterwards.

Many noble Lords asked about the capital budget and quite reasonably asked why the Bill is about only revenue, not capital. The Bill is very much about protecting the record revenue spending for NHS England. However, we all know and totally acknowledge the requirement for capital investment. The Government have already made significant commitments: 40 new hospitals, with £2.7 billion for the first six; a further £2 billion capital spending, including £850 million for the first 20 hospital upgrades; and so on. I reassure the noble Lord, Lord Warner, and others, that further decisions about NHS capital will be made at a fiscal event in the very near future.

I note the comments of the noble Baroness, Lady Tyler, about the mental health estate and the use of wards. I reassure the House, and the noble Baroness in particular, that her arguments have been heard loud and clear. The Government recognise that the mental health estate is not satisfactory and are looking at ways to modernise these out-of-date buildings and arrangements.

The noble Lord, Lord Young, made a plea for GP surgeries. This resonates with me personally. The patient experience of arriving at a GP surgery is essential. Time and again, from my own experience, from what I know of human nature and from what I hear from patients, it is an unhappy one. In particular, the role of the receptionist at the GP surgery is unfortunate. I feel enormously for front-line professionals who have to deal with triage and the awkward conversations that take place. Something must be done to rethink the way we present ourselves to patients and that initial interface through the receptionist: a patient-first modernisation will be important.

--- Later in debate ---

[Lord Bethell]

My noble friend asks a question of such philosophical Whitehall subtlety that it is way beyond my pay grade to provide a clear, etymological answer to that. However, I reassure her that the matter is an enormous priority, and when I go back to the department I will lean on it hard to deliver this important publication.

The commentaries of my noble friend Lady Penn and the noble Baroness, Lady Tyler, on the visibility of spending on children’s mental health was important. The Government are 100% aligned on this. I noted the Minister of State from another place standing at the Bar, nodding with agreement while those words were being said. I know that a meeting has been agreed on this matter and a date is in the diary, I believe for next week, and I very much look forward to the outcome. I reassure the House that this question of visibility and publication is taken ex3tremely seriously.

The noble Baroness, Lady Tyler, asked about the mental health investment standard. CCGs are required to increase investment in mental health, as discussed earlier. All CCGs are on track to meet that standard, as the noble Baroness, Lady Hollins, rightly pointed out in 2019-20. I suggested in my previous speech that it would be premature to legislate for specific aspects in the Bill and capital will be considered in other fiscal events.

The noble Lord, Lord Bradley, spoke movingly about children’s mental health. I reassure the House that, in addition to increased mental health funding, we are implementing a progressive programme of transformational change for children and young people’s mental health services. This will include incentivising every school or college to identify and train a senior lead for mental health, creating new school and college-based mental health support teams, and piloting a four-week waiting time for children and young people’s specialised services.

The noble Lord, Lord Hunt, the noble Baroness, Lady Finlay, and others brought up the sensitive subject of adult social care. Fixing that long-term issue is one of the great challenges that this Government have taken to their shoulders. The reassurance I can give noble Lords is a political one. There are many complex questions to address, but our pledge as a Government has been clear: everybody will have safety and security, and nobody will be forced to sell their home to pay for care. Delivering on this promise will require an enormous amount of stakeholder engagement and political bridge-building, and we are embarking on that important process.

The noble Baroness, Lady Finlay, was quite right to say that social care workers are wrongly described as low skilled. I entirely agree with her sentiments; they are low paid but highly valued.

I am running out of time and have a few more points to make. I will jump to the conclusion and say that the Government take this Bill very seriously. The execution of the money involved in the Bill is also taken very seriously. There have been a number of exciting, important ideas about how that money should be spent from the noble Lords, Lord Willis and Lord Kakkar, among others.

We made our commitment in the manifesto and the Queen’s Speech to enshrine record NHS funding in law. We are delivering on that commitment and putting the NHS on a secure and stable footing for the future. The NHS belongs to us all, and this Government are backing that idea. I commend this Bill to the House.

[Lord Warner]

Before the Minister sits down, I have a question. I have been digesting his answer to me on inflation-proofing. Is he saying one way or the other whether these figures will be inflation-proofed annually, with the passage of time? Two-thirds of NHS costs are pay, and there will presumably be some pay increases. What is the Government’s position on inflation-proofing these figures?

[Lord Bethell]

It is the convention in the Treasury to express spending commitments in cash terms. That is the convention of government and how this Bill is expressed. It is not the commitment of government to uprate these figures necessarily according to inflation. They are adjusted for all the potential inflation that may happen. That said, if unexpected events happen or pressures are great, there is the opening and the capacity to increase spending if necessary.