The Long-term Sustainability of the NHS and Adult Social Care

Lord Carter of Coles Excerpts

Thursday 26th April 2018 Lords Chamber

[Lord Carter of Coles (Lab)]

My Lords, I too congratulate the noble Lord, Lord Patel, on his introduction and his excellent chairing of the committee that produced this really authoritative report. We should not be surprised that it is so authoritative when we look at its members: there was clinical input, operational input and political input, all critical for navigating and producing a successful healthcare system. I refer to my interests in the register but will specifically mention a non-executive position on the board of NHS Improvement.

There is a high degree of consensus on the need for long-term funding and planning. Ministers are beginning to listen and the signs are good. We must get away from stop/go: it leads to all sorts of asset misappropriation and degrades the system over time.

I will touch on four points, starting with integrated care. Much has been made of this. Someone said to me the other day that the English system is so fragmented—for many reasons—that it was like having a bad aeroplane journey: you have a bumpy take-off, a pretty smooth flight then a bumpy landing. Getting in and out of the system causes enormous difficulties. We have fragmented it, and we need, in bringing NHSI and NHS England much closer together, to do away with that fragmentation.

A key fault line in the system—as has been mentioned by other noble Lords—is the breakdown between acute care and long-term care for adults. It is a serious problem that is bedevilling the system. There are probably more than 10,000 people in our hospitals who should not be there. The effect is that we cannot perform the elective surgery and the system starts to spiral downwards. If the Government could do one thing quickly—this is about the long term but they need to do some things quickly—it should be to solve the problem of how to move patients out of the acute care system. Perhaps we should look at other healthcare economies, where central, rather than local, government funds the first 30, 60 or 90 days in the post-acute phase.

We need to look at other systems. The other day I was walking around a hospital in the United States with the lady who ran the trauma and orthopaedic department. I asked her what the average length of stay was for a total hip replacement. She looked really put out. She said that it was 56 hours. I said that sounded pretty good to me and asked what it should be. She said that it should be 52. We measure our length of stay in days: it is five and a half days, which is 130 hours. Other systems have developed because they have appropriate people in the care pathway. They have developed step-down care and homecare. In theory, people can move through the system and be cared for in the most appropriate place, both clinically and financially.

Integrated care is crucial, and the point was made earlier: we know how to do this. As someone said, the NHS has done everything right once. The challenge it faces is how to do things at scale: how to take its great skills—something that I will return to—and spread the productivity.

On integrated care and the issue of funding, whether that is a hypothecated tax or whatever, we must mutualise the risk. We do not want individuals bearing the risk and the fear that goes with it. We all agree on that but what form it will take, we will see. The critical point is: how do we involve citizens in the spending of that healthcare money and make them aware of what is spent? Do we take the French system and send them a statement every year saying, “This is what we spent to keep you in the state you are”? Or do we have a system like that of Singapore, where there are individual healthcare savings accounts and the citizen takes an active part in spending that money? Getting the total funding package is right but involving the citizen will be critical if we are to build a modern healthcare system.

I have worked on productivity for some years now in the NHS. It is inconsistent across the whole picture, in terms of not only money but care output and outcomes. Under the CQC ratings, there are 230 provider organisations in England. Of those, 12 are highly rated; 103 are good; 103 need improvement; and nine are obviously in serious difficulty. We have excellent hospitals—excellent community hospitals and mental health providers, and some of the great acute hospitals in the world—but we fail to take the learnings from them and spread them through the system. We are short on some degree of information-sharing and standardisation, although in fact we are quite rich on information. In many ways we do not use it properly or turn it into action, so it is quite critical.

People are beginning to think about this in NHSI. The noble Lord mentioned the work that Professor Briggs and Professor Evans are doing on standardising clinical pathways under the GIRFT programme. We are already gradually seeing the influence of people doing things in common. I think it was Benjamin Franklin who said, on the signing of the Declaration of Independence, “If we don’t all hang together they’ll certainly hang us separately”. What has happened in the NHS is that we have been hanged separately by vendors or suppliers of materials, et cetera, so we need to hang together a little. Where we get that hanging together, we see savings. We have seen that this year in pharmaceuticals, where we have taken £300 million-odd out in the last year just by behaving collectively and switching purchasing in a proper manner.

That leads me finally to the issue of staff. People have talked about training and the need for it. All the time, we hear the praise for our dedicated NHS staff but perhaps we should turn to the annual staff survey and ask ourselves why 25% of the staff across the system feel harassed and bullied. I know of no other healthcare system in the world where that would work; in fact, for anybody involved in employing large numbers of people, anything above 10% is certainly a warning signal. In a good healthcare system, frankly, anything above low double digits is a crisis. We need to go back and understand this. Perhaps the Minister can say what is being done. The report talks about the effect of pay on morale but maybe we need to understand the effect of culture, management and pay on the critical issue, at this time of staff shortages, of how we use that scarce resource.

This report should shake our complacency. We seem to have a sort of schizophrenic attitude to the NHS. On the one hand, we are incredibly proud of it and think it is the greatest thing, yet when we look objectively we are failing. We are not as good as we should be, yet we have the perfect structure. What we need to do is to operate it better and we are beginning to work out how to do that. The question is: can we go at pace and move quickly enough? We need to convince the funders that as the money comes it will be spent wisely, and convince the public that we are spending it sensibly. We are on the edge of that but it will require an enormous push from government to get it there.