National Health Service
Lord Filkin Excerpts(8 years, 6 months ago)
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Lord Filkin (Non-Afl)
My Lords, I thank the noble Lord, Lord Turnberg, for this extremely important debate. I declare an interest as chair of the Centre for Ageing Better, a new What Works Centre that does what it says. I will focus on the implications for the NHS of an older population and I shall seek to look 10 years forward, as I think it is essential that we do so in order to address this question.
The starting point is that we are living longer, and this is a cause for enormous celebration and thanks. There are people in this Chamber and in our society who are alive now who would not have been without the changes and successes of medical science. So we should address this as a fantastic opportunity to consider how we benefit from longer lives, rather than seeing it as a disastrous crisis.
Nevertheless, we have to face up to the scale of change and challenge. The ONS tells us that in 10 years’ time there will be 40% more people aged 85-plus. We know what that implies for the NHS in terms of demand and cost. We know that it means many more people with long-term conditions—there are some estimates in Ready for Ageing? if noble Lords want illustrations—and we know from the five-year forward plan that long-term conditions drive 70% of NHS costs. So one way or another there will be a major increase in the proportion of GDP that we spend on health and social care over the next 10 years. Wanless estimated about 11% of GDP; the King’s Fund report by Barker estimated about 12%. Those give us the scale of increases in GDP spending that we are likely to make by one means or another.
What should we do? I agree with the noble Lord, Lord Fowler; it is not the model that is wrong. The model of the NHS is fundamentally equitable and relatively efficient and low-cost compared to others. The question is essentially: how do we fund an NHS and a social care system to address this?
Prevention is critical; it has been talked of, so I will say only two sentences on it. Wanless said in 2002 that unless we address prevention we will hit a crisis; the NHS Five Year Forward View said that we have now hit that crisis because we failed to address prevention properly. At present there is no ambition, plan, leadership or social debate about how we will make the major shifts in personal attitudes and behaviours that will avoid self-inflicted damage and cost to individuals and the public purse later on. Many lives are poorer because of that, so we have to address it, and although it will be slow to make change, it is fundamental to success.
In conclusion, on how we as a society pay for between 11% and 12% of our GDP on health and social care to benefit from longer lives, the question is clearly how we do it in a way that is fair to all people. We need to recognise that many of today’s pensioners are better off than ever. Pensioner poverty has been largely eradicated, and pensioners have a very privileged tax and benefit status—I celebrate that personally. However, in truth the question is: what is the political agreement with the public? Is it essentially, “We will protect you in a privileged tax and benefit position” or “We will commit as a society and as politicians to protect the quality of health and social care that you will need in an equitable way in our society so that you will benefit from your longer lives”?
Residential Care: Cost Cap
Lord Filkin Excerpts(8 years, 7 months ago)
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Lord Filkin (Non-Afl)
My Lords, I declare an interest as chair of the Centre for Ageing Better, a new What Works centre promoted by the Government and well-endowed by the Big Lottery Fund but with full independence from both. I thank both for their wisdom in promoting it. The centre seeks to seize the benefits of the longer lives of more older people, so that we all benefit from that.
Some noble Lords will remember that two years ago this House produced a report, Ready for Ageing?, which set out the enormous opportunities of longer lives. It also made very clear that both individuals and the Government had to change to avoid a series of miserable crises—to quote roughly from it. I fear that what we said then has come to pass and we are now in the midst of a miserable crisis on social care, which I fear will only get worse.
Most of this debate will be spent talking about the immediate crisis. I am not going to do that; it has been well covered by other noble Lords. I will suggest instead that it is essential to look forward five or 10 years in public policy and public debate. The number of people aged over 85 will have increased by 17% by the end of this Parliament. In 10 years’ time, it will have increased by 40%. This is a social revolution and it matters because most formal social care is focused on those aged over 85. Another National Audit Office figure shows that 50% of those aged over 85 require some form of social care. We have clear evidence of rapidly rising demand and have experienced some of it over the past few years.
The Commission on the Future of Health and Social Care said:
“The government appears … to have no strategy whatever to tackle the rising and pressing needs for social care”.
I regretfully agree. This matters massively. We are talking about our oldest old in society and how they are treated with decency. We are talking about very fundamental things—help to get out of bed in the morning, help to wash or to bath and help to put on shoes and socks, let alone other forms of care. It is not some abstract debate about public policy.
What is needed by all of us—the Government as well—to address this? There is not time in seven minutes to give more than a very crude agenda, which most noble Lords know already. We clearly know that people wish to sustain their independence for as long as possible; therefore there is a serious question about what needs to be done and what works to sustain an individual’s independence. We all know we have to grow and support informal care. It is the foundation of care in our society and I am glad the Government are making progress on how to support carers more. We also have to use the asset of more older people and community action to address how to support more frail and ill older people. This will deal only with lower levels of need. You cannot expect some of the really heavy lifting to be done by individuals and volunteers.
That takes us to the fundamental question about what sort of supply of care we need to cope with the certain rapidly increasing demand we face. It is obvious that we need more home care because it is fundamental to making the system work well. We will need more residential care—that is a starting point. ResPublica estimates that 15% more residential care will be needed within five years. Even if it is wrong by three percentage points, it is a significant increase. We need, above all, a much bigger and more skilled care workforce to cope with more residential, domiciliary and palliative care.
Yet the consequence of local authorities, which dominate the market, being starved of funding is that we are driving down supply and weakening the ability to build a workforce for the future. There is not much sign anywhere that anybody has a strategy either for workforce and skills growth or for generating the mixed supply of domiciliary and residential care that our public will need as we go forward. That is staggering and horrific.
I shall give your Lordships one piece of evidence that shows why the care market is going south when it should be going north. Professor Martin Green, the chief executive of Care England, wrote to me this week. He said that Care England, which represents carers across all sectors, is now recommending to care providers that they should try to withdraw from the publicly funded provision of social care. That is on-the-record advice, and noble Lords already know why it has been given. It is a shocking situation.
I would like to ask why we are where we are. None of what I have said is news to good officials in the Department of Health, and it is not news to a good, thoughtful and well-informed Minister. What I have said is all known but we are not seeing action—for two reasons. One was set out very well by the noble Baroness, Lady Brinton, and it relates to the hidden misery. Hundreds of thousands of people are suffering in invisible places and, unlike the NHS, they do not have political salience. The second reason—I am not being party-political; your Lordships can see where I now speak from—is that the Ministers in the Department of Health are trapped within the Government’s fiscal and political stance. I do not deny the importance of fiscal balance but it is clearly possible to achieve fiscal balance and better care at the same time if you apply your mind to it and if you give bold political leadership. Fiscal balance is necessary but we also have to grow a market and a workforce to cope with social care.
As I get towards the end of my remarks, I ask your Lordships to consider the irony of a political stance—which many of us understand—that involves seeking to protect pensioners in a very privileged way in relation to tax and benefits. That is what has happened in our society and it is the stance of the current Government. Yet, at the same time, the Government are withdrawing funding, which means that now—and the situation will become even more serious over the next five to 10 years—hundreds of thousands of pensioners will be deprived of the support that they will desperately need in order to live in circumstances where there is respect and decency.
Trivialising matters slightly, we should ask whether many of our older people would be prepared to trade some of the highly privileged tax and welfare benefits that they now get so that they and others who are older can benefit from the required levels of support and decency. A strategy will be required, as well as consistent public funding, to ensure that those in the greatest need are properly cared for. That will require a much more grown-up debate than I have seen any sign of yet on how our welfare settlement needs to adjust in order to cope with the many more older people who will have the opportunity to live longer lives. We are obviously not facing up to the changes that we need to make in public policy but it is urgent that we do so.
Ageing: Public Services and Demographic Change Committee Report
Lord Filkin Excerpts(10 years, 9 months ago)
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Lord Filkin
That this House takes note of the Report of the Public Service and Demographic Change Committee Ready for Ageing? (Session 2012–13, HL Paper 140).
Lord Popat (Con)
My Lords, there are 21 speakers for the debate this evening. If the Back-Benchers stick to five minutes for each speaker, that should enable the House to adjourn by 7.15 pm.
Lord Filkin (Lab)
My Lords, our ageing society is by far our biggest social change, bringing great benefits. Many people will live longer, much longer than might have been expected, and in doing so will contribute much to our society and economy, and will benefit personally from this longer life. This change is happening now. There will be 24% more people aged 65-plus in our present decade, and the change will persist for decades to come. By 2030, there will be over 100% more people aged 85-plus compared to 2010. Our report explored what we all need to do to maximise the benefits of this great social change. The House will be relieved to hear that I will be assuming that all Members have read it, given that it was only 10 pages long; I will pick out a few of the highlights.
First, I offer warm thanks to a talented and challenging committee. You could not get a better committee of Members to work with than we had. They were superb and their commitment and contribution was very great indeed. I also thank our two special advisers, Howard Glennerster and Jonathan Portes; it is particularly good to see Professor Glennerster with us today. I also thank our excellent staff, Bina Sudra, Tristan Stubbs, Tansy Hutchinson and our quite remarkable clerk, Susannah Street. I thank Philippa Tudor for the quiet support she gave in the background to this process. We had a remarkably pressured timetable, trying to deal with 70 witnesses in about three months, and she was very helpful indeed. Lastly, I thank the House itself for agreeing to the suggestion for this ad hoc Select Committee.
How, then, do all of us need to change to be ready for this ageing society? Clearly, first, as individuals, our prime responsibility is always to try to manage our own lives ourselves rather than to expect others to do it for us. Clearly, people need to understand the probabilities and risks consequent on ageing—that they may need to save more, to work for longer, to at least make provision for their social care and to think about how they care for others. Individuals also need to engage with the choices and behaviours that are likely to make for a healthier and happier longer life. We have control over quite a lot of things—at least, some of us do.
It may well be that many people need trusted, accessible, person-centred information and evidence to make these informed choices and, hopefully, the behaviour shifts that might go with them. Clearly, civil society itself will have to make changes in how it will need to engage with ageing and how it can better work to support the many more older people in our society. It would be naive to think that the state, either central or local government, was able to support all the increased numbers of people in our society. Yet there is enormous potential if civil society itself engages positively in this and the question, of course, is how we stimulate such a growth of civil action.
Clearly, civil society also needs to understand the choices that we all have to make collectively as a nation to address the changes and some of the pressures and choices consequent on them. Finally, we need to use the assets of many more older people as a resource that is able to contribute to meeting the needs of other older people. That is obvious to many of us and axiomatic. Again, we need to think about how we make it happen in practice.
There needs to be much greater engagement with ageing from businesses generally, large and small. Ageing affects our economic growth, our fiscal position and the supply of labour to businesses, which others may speak on later. Business needs to become much more positive about flexible working for older people, otherwise we will have labour supply problems, less economic growth and less fiscal contribution than we otherwise would. In other countries, particularly Germany, business is actively engaged in these debates. I look forward to hearing invitations to discuss these issues from some of our business leadership figures, not least the CBI.
Local government will clearly be at the fulcrum of ageing at local level. In some local authorities, the scale of the changes in their older population is quite remarkably greater even than the dramatic figures I have given already. Clearly, local government’s role has to go way beyond just the management of social care, although that is already an enormously taxing role for it. It has to address the failures of planning and housing supply for older people at a local level, which clearly cause greater problems for many people and clog up family housing that could be released. Local authorities will need to work with, and generate greater engagement from, the voluntary sector and civil society to increase volunteering, to support attempts to reduce loneliness and isolation, and to contribute towards informal social care. We will need a quite remarkable scale of increase in informal social care. Again, it would be naive to think that the state will deal with all those things by itself. There is, therefore, a very large range of roles for local authorities over and above their new public health role. One would expect to see thoughtful local authorities making estimates of the scale of demand that they will face, and starting to have dialogues with their communities about how they will plan for and address those great opportunities and pressures.
The voluntary sector—which I recognise does enormously good work—will itself want to consider, individually and collectively, how it will need to change to make a greater contribution to meeting the needs of an ageing society. I doubt that doing what it has done in the past, or even doing more of what it has done in the past, would be adequate or sufficient. Therefore, we have already started discussions with some of the key voluntary sector organisations about how they need to assess the scale of future need and how they will raise their game to meet the future needs that will be required of our society.
Public health at national and local level is, I think it is obvious to all of us, a central issue in how we address ageing. I will give one simple illustration. If, over the next 15 years, we were able to shift the behaviours of many people in our society so that they made healthier lifestyle choices about diet, weight, exercise, smoking and drugs—and we all know ourselves how difficult some of those resistances are—the personal, fiscal and economic benefits would be remarkable. I argue, both to government and to civil society: think of what we have done on smoking, but also think of how we make these changes. They start to make coping for an ageing society more bearable in public policy terms, but they also make individuals’ lives that much happier and more fulfilled if they are able to enjoy them in that way.
On the NHS, I think we would all acknowledge that the fact that we are living longer is due in part to the great success of medical science and of the NHS itself, combined with many people making better lifestyle choices. That, therefore, is to be celebrated. Nevertheless, an ageing society is by far the biggest challenge that the NHS has faced since its foundation. I will give three reasons why that is the case. First, there will be an enormous increase in the number of long-term conditions in our society, consequent on many more older people, many more much older, older people, and the propensity that that causes to generate long-term conditions. In the past you died of certain conditions; now you live many years longer with those long-term conditions. That is a wonder, but it has challenges.
Secondly, there will obviously be very great increases in cost for the NHS and for social care, consequent on that increase in long-term conditions and social care needs itself, so we will see remarkable increases in cost hitting the system as well. Thirdly, every bit of evidence we received, and all the expert opinion—including the briefing noble Lords have received from the NHS Confederation—is of one mind that the system needs to go through quite a remarkable change so that it moves to the better management of long-term conditions in the community and away from what is essentially an acute and hospital-centric focus. Everybody broadly agrees with that diagnosis; the challenge is how it is going to be made to happen.
The problem—without wishing to be party-political for a second—is that politicians do not always give the impression that they are facing up to the scale of those three issues: the scale of increased demand, increased cost and how to bring about that system change. We all hope that NHS England, when it produces its strategy in the autumn, will set out a clear vision as to how that should be addressed, both assessing the demand and setting out how it thinks the system should change to do so. However, even if it does that well, it will not be able to do it without clear, strong, consistent political leadership, preferably supported by all political parties.
How has central government responded to our call for action? First, we all recognise that central government is not responsible for all these challenges. They are issues for all of us. However, many of us consider that central government is responsible for leading the debate and setting out the issues so that we as a society can face them rather than hide from them. It is also remarkable that there was no rebuttal in the Government’s response of the fundamental evidence and analysis that the committee set out in its paper. They did not say that we got it wrong; they were almost totally silent on that. Therefore, it is reasonable to assume that the diagnosis we presented was reasonably accurate. That has been the view of many experts, as well.
We were disappointed not to see from the Government a vision statement, or a commitment to produce some sort of vision, about what they think we should do for our older society in future, and some sort of outline of how, as a society collectively—central government and civil society—we should go about making that vision a reality. They have also resisted our request to set out an honest debate with the public about the opportunities, challenges and changes. We argued for a White Paper and a Green Paper to set out the issues so that we could all engage with them seriously. They did not respond to that. In part I know why, but it is a great shame, because that is what we all need.
In my final few minutes, I will say a little about what we have done to maximise engagement with the Government on this report. Our committee ceased to exist in March, but we chose to ignore that and to continue having very vigorous discussions among ourselves, and excellent meetings with Ministers and senior civil servants. We tended to go in twos, as is our way, whenever we could. I met five or six Ministers, virtually all the top civil servants relevant to this, and special advisers, and I thank them all. Without exception, the conversations were thoughtful, and with many officials we could discuss both policy and politics—realities—at the same time, because those things are real.
Next we should acknowledge that the Government have done some very good things in a difficult environment. They have made remarkable progress on pensions reform and on putting into practice the fundamentals of Turner. Steve Webb is to be commended on that, in an incredibly difficult fiscal context. That is good progress, but, as we said, it is the start, not the end of the story.
The situation is similar with Norman Lamb and social care. It is not the thing to mention this week, but we should recognise that Dilnot, even if you did not think that it was the perfect answer, was a brave and difficult thing to do, and was not always welcomed by the Treasury. Again, that is to be commended; it gives us a basis to move forward. We will have to get the details right as we work on it.
We have had discussions with Mark Prisk, the Housing Minister, as well as with Norman Lamb. We had excellent discussions in closed seminars about what the report said, and there was a recognition in the Government’s response that there were significant failures in current policy and practice. The market in specialist housing for older people does not appear to be working, and there is a need to do something about that. Again, I commend the honesty and engagement that we have had there.
I wish I could be as positive everywhere, but, as noble Lords will sense, I am not going to be. What still amazes us as a committee is that we have not seen from the Department of Health any published data of its estimation of the increasing demand consequent on the absolutely certain increase in the number of older people. Perhaps we will get that from NHS England; let us hope so. It is fundamental to the situation. When you know that you will face massive increases in demand, you make some assessment of what that will look like and you then think about what it implies.
Secondly, there is still a doubt over the Government’s narrative that the massive systems changes that we all recognise need to happen will just come about organically in a bottom-up process. Clearly, the leadership of the NHS and the health service generally looks for clear, solid, consistent ministerial support for these changes. That is difficult, but they will not happen without it. Lastly, we need an honest conversation between politicians—hopefully of all parties—and the public about the changes that our NHS will face.
I am coming towards the end. I will now deal with the fiscal implications of this. As noble Lords will know, the dependency ratio is obviously worsening as a consequence of these demographics, and I will not go into detail on that. Many more older people, and older old people, will mean much more spending on pensions, health and social care. It is axiomatic that that will happen. The debate is about how much of that extra expenditure should be paid for by the state out of taxation and how much of it should be paid for by individuals themselves. However, it will have to be paid for one way or the other because our society will demand a level of care and healthcare befitting a civilised society. Therefore, we must face up to a discussion on that.
Apart from what the Nuffield Foundation and the IFS have produced, to date we have not seen much indication of the scale of that future cost. However, the material that has been produced is frightening enough. It signals a gap of at least £35 billion, and probably £54 billion, by 2021-22. The IFS told me that those figures had been reached just by looking at the 4% per annum historical trends; not by assessing the elemental increase in demand consequent on having more older people with long-term conditions, so I think the figures, are, if anything, likely to be an underestimate. We have to discuss as a society the implications of how we fund these increased public service costs. There are no right or simple answers to that, but thoughtful discussion, preferably across the party divide, would be helpful. Ideally, I think that some Turner-style process that commanded cross-party support would be a healthy approach.
We have not seen what we hoped for from the Government in terms of a Green Paper or even a ministerial subgroup to look at these issues. However, I hope that all is not lost. We are 18 months away from an election. Although I have been putting these questions to the Government, it seems to me they are equally questions for all three political parties. We hope that all three political parties engage seriously with these questions over the next 18 months, and, we hope, do so in a more transparent way so that there is a proper engagement by experts in their thinking about how we as a society address these challenges.
I am pleased to say that one of the consequences of our work is that eight major charities came together into the Ready for Ageing Alliance. They will work with our committee and maintain a constant dialogue with experts and politicians about these issues over the next 18 months. No doubt they will inspect the election manifestos, and the work behind them, of all the major parties.
As noble Lords sense, my committee members and I think that these are important issues. We will not let them go. We look forward to further discussions in the House and with wider and civil society about them. The benefits of getting this right are enormous, but if we are in denial on these issues we will massively underestimate those benefits.
Lord Filkin
My Lords, I thank the Minister for his thoughtful response, as ever. I thank all who have spoken so powerfully, whether from humanity, policy or politics in different dimensions. I particularly enjoyed, as did we all in the Chamber, the superb maiden speeches of the noble Lords, Lord Livingston and Lord Borwick. We could not have been better served. Above all, I was pleased as one of the committee’s goals was to get all political parties to commit to working on these issues in their manifestos. That was explicit in our report and we heard, I think for the first time in public, two political parties saying that they would do so. That is good news and I am sure that we will get the third before long.
I should have mentioned one member of staff who I forgot: Owen Williams. He was our press officer and was genuinely superb. He got almost everything right, except for the final day. At about 10 pm on the night before our launch, we know that we had the lead spot on the “Today” programme the following day. Then the College of Cardinals elected the Pope. Owen had failed to control the College of Cardinals and we were bumped off the top slot. You cannot get the perfect staff, can you?
In conclusion, the noble Lord, Lord Mawhinney, was good at giving me strong advice—the committee will recollect this. He did not mince his words and at the end of the process I asked him, “What do you think I should do now?”. He said, basically, “Keep going”, and he made me think that that was the right thing to do. I thank him for that because we have kept going, which is sensible even if we are not really a Select Committee anymore. We will keep going and I will wish to discuss some of the excellent ideas that I have heard in this debate to see how we can pick up on them. I thank all who have spoken.
UK: Ageing Population
Lord Filkin Excerpts(11 years, 4 months ago)
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Lord Filkin
To ask Her Majesty’s Government whether they will publish their assessment of the implications of the ageing of the United Kingdom’s population and their response to those implications; and, if so, when.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
We welcome the committee’s report on the ageing population that was published last week. We will consider its recommendations carefully and respond in due course. Effective reform of public services is critical if we are to meet the needs of an ageing population and ensure long-term sustainability. We have put in place an ambitious programme of reform across a wide range of government policy areas, including pensions, health, social care, housing and employment.
Lord Filkin
I thank the Minister for his reply. As the House may know, the committee found that our society and Government were woefully underprepared for this major social change. To focus the supplementary question on health, out of courtesy to my colleague, the report found a massive increase in demand and cost driven by the increase in long-term conditions. In the committee’s view, this posed perhaps the biggest challenge the NHS has ever had to face. Will the Secretary of State set out his assessment of these challenges and what he proposes to do about them?
Earl Howe
My Lords, we know that to adapt and respond to future need, the health and care system needs to change. The conclusions of the noble Lord’s report correlated in many ways with our own analysis in this respect. The challenges that the report sets out create an opportunity for the NHS and local authorities to innovate and explore new ways of working together to meet the needs of their local populations better and to optimise the use of resources, which is of course critical. We think the NHS and local authorities are best placed to understand the opportunities that exist in their areas, and we are committed to supporting them in that regard.