National Health Service: Sustainability

Lord Crisp Excerpts

Thursday 9th July 2015 Lords Chamber

[Lord Crisp (CB)]

My Lords, like others, I agree that the noble Lord, Lord Patel, is right about the need for a fresh look, going beyond politics and all the experts. We need to reframe the arguments and get others into the debate, and to take a long-term view.

I agree with the many people who have spoken, starting with the noble Lord, Lord Fowler, about the importance of understanding and reviewing how the NHS is financed. However, I want to take these arguments a bit further and think about sustainability in the round. Sustainability is not just a financial issue. I shall give two examples. Barely 50% of children have met all their development milestones by the time they start school. This influences children’s future physical and mental health and their ability to learn. The second example is that social isolation and loneliness in old age have the equivalent health impact of smoking 15 cigarettes a day. Moreover, loneliness very much slows the rate of recovery. Your Lordships can see where I am going with this argument. I have deliberately chosen two issues that are not directly about healthcare yet the NHS has to pick up the pieces; in most cases it cannot have a direct impact on these issues, although others can.

Sustainability is wider than that, too. If the NHS and social care are the formal healthcare system—and we have heard the figures for what that costs—the latest figures from carers’ associations is that if we were to monetise what carers provide, we would see that they provide about £120 billion worth of care. If you add into that what civil society, volunteers and all the NGOs and so on do, you see that there is a vast informal care system. My point in raising that is that what happens in the informal care system impacts on the formal care system, and vice versa. If the informal care system gets weaker, it puts more pressure on the NHS, and if the informal care system gets stronger, it takes some pressure off it. These are important points about sustainability, and any future commission needs to be thinking about these as well as how to finance the NHS.

A lot has been said about prevention, but we also need to think about this in a different way as being a positive term, sometimes called “health promotion”. It is about the creation of a resilient, healthy population and society. The Minister knows that I have a debate—later in the autumn, I hope—on what I call “health creation”, which is precisely what we are talking about here. There are two simple points here, and I will not go any further: we need to think about sustainability in the round, and the NHS itself cannot make itself sustainable—others have to play a major role in that.

My second point is that looking at financing is right, and clearly we need to chase improved efficiency at every level. However, we should not hope for too much from a review of a new financial model. I will give just two examples from around the world—again, I do not have time for more. Holland changed its system with great fanfare about five years ago so that it consisted of private insurers which then purchased from anybody. The net result of that, which was probably predictable, was that unit costs have gone down and volumes have gone up, and Holland, which now spends 25% more than we do, is spending more than it did. That was an experiment in changing the financial arrangements.

I will not talk about co-payments—that is, getting people to pay as well—other than to say that all the studies show that if they are to be big enough, they will affect both the poor and the rich: they affect the behaviour of the rich, who then go elsewhere, while the poor cannot afford to pay for services. You can have small co-payments, but large ones have those impacts. My point is that we must look at how the NHS is financed—I understand and agree with that point—but we should not hope for too much from what others around the world have done.

My third and final point is that in the short term you cannot take politics out of the NHS. To go back to Holland, the Dutch Government do not directly run hospitals, but the Dutch Health Minister gets all the questions about hospitals in his Parliament anyway. However, we can have a cross-party consensus about the longer term.

I will quote from a Portuguese report—if noble Lords allow me, I will say it in English; indeed, your Lordships may prefer me to do so. Portugal is trying to transition from today’s hospital-centred and illness-based service system where things are done to or for a patient to a person-centred and health-based one where citizens are partners in health promotion and healthcare. It will use the latest knowledge and technology and will offer access to advice and high-quality services in homes and communities as well as clinics and specialist centres. It will provide a better service with lower infrastructure costs. That is Portugal’s aim over 25 years. It will not be difficult for us to construct that sort of consensus and vision about where we are trying to go, but we need to understand that that is a radical change. If we are to have a radical change and we are pointing in that direction, we need a clearer longer-term plan than the five-year plan we have, and we need the sort of transition fund that some people are arguing about.

My final point is that I absolutely agree with the proposal of the noble Lord, Lord Patel, that there should be an independent reframing of the arguments, which will bring other people into the argument so that the same people are not having the same arguments, which has often been the case in the past. To do that, the starting point is to create that shared vision of where we are going, so at least we have something to steer towards, and we need to understand that sustainability is about these wider social impacts, not just about the efficient management of money within the NHS, important as that is.