NHS: Staff Numbers after Covid-19

Lord Horam Excerpts

Thursday 4th March 2021 Grand Committee

[Lord Horam (Con)]

My Lords, I was appalled to read last week that the Government now say that recruiters for the NHS and care homes can actively target 105 countries that were previously blacklisted on ethical grounds. These countries include Zimbabwe, Jamaica, South Africa and India, all of which have an acute shortage of doctors and nurses. India, for example, has 0.8 doctors per 1,000 people—the UK has 2.8 per 1,000 people. It is therefore ludicrous for the Government to say that recruitment from these countries has suddenly become ethical. It has not.

We need a proper workforce strategy. As a result of Covid and the great work of existing NHS staff, wherever they come from, there is real enthusiasm among young British people to work for the NHS—applications for nursing courses, for example, were up by 35% last year —yet medical school places increased by a paltry 500 in the last year for which I have figures. There is a double betrayal here: of those in poorer countries whose doctors and nurses we are stealing, and of the unemployed in this country who we are failing to train. It is shameful.

Queen’s Speech

Lord Horam Excerpts

Thursday 9th January 2020 Lords Chamber

[Lord Horam (Con)]

My Lords, I am slightly surprised but delighted to be the third northerner in a row to speak from these Benches, following on from the very affectionate remarks made by my noble friend Lady Wyld and the remarkable experiences in farming and so forth of my noble friend Lord Inglewood. I was born in Preston in Lancashire and I therefore complete the trio. The fact that all three of us are Conservatives shows that the House of Lords is not as behind the times as we sometimes think. We are right there, bang on trend, because of course the main feature of the general election was the extraordinary success of the Conservative Party in winning seats in the north and the Midlands. This does mean that the Prime Minister—I will point this out very firmly to him whenever I see him, although that is not very often—has to deliver to the towns and cities of the north of England and the Midlands. It can be done.

Many of our northern towns, as northerners will attest, have wonderful civic buildings from the time in the 19th and 20th centuries when they produced most of the wealth which we lived on at that time. It now comes from London, but back then it came from the north of England. Anyone who has not seen the Harris Library in Preston or Bolton Town Hall has not really lived—I thank my noble friend from Bolton for nodding. These are wonderful buildings, but the problem is that much of that area has become run-down as a result of the manufacturing rundown and so forth, and now needs help. However, I hope it is not just the civic areas that will be helped by the northern powerhouse but the smaller towns. I therefore particularly welcome the £3.6 billion put behind the towns fund, which will help the smaller communities and towns that need that sort of help.

As we have said throughout this debate, this is also about skills. The fact is that the apprenticeship levy is not working as well as it should. We need more technical education. All these areas are highly relevant to the north and the Midlands. We also need to reconnect. The fact is that we have not connected the regions with London as well as we could have in the past.

I also think that poverty in this country is a particularly urgent question. What has happened to universal credit is not good. It needs urgent attention. As my noble friend Lord Forsyth and the noble Lord, Lord Lipsey, said, there is considerable agreement on social care but what is needed, above all, is a big cheque. Therefore, we need to ensure we can afford all this activity. I think we can because, first of all, we can take a more relaxed approach to debt now that the 2008 financial crisis is well behind us. Ten-year yields on UK Treasury bills are down from 3.5% in 2010 to 1.25% today. Therefore, enhanced borrowing, properly presented, is also a possibility.

Like my good noble friend Lord Tugendhat, I think that if we cannot deal with this through a more relaxed approach to debt, we have to consider increasing taxation. I point out to the House that we are a lightly taxed country, relatively speaking, by comparison with our European neighbours. In the UK, tax as a percentage of GDP is 37%; in the Netherlands, it is 40%, in Germany, 41%, in Denmark, 46%, and in France, no less than 48%. I am not suggesting we go the full French—far from it. None the less, a tweak or two on that percentage would not go amiss and can indeed be done. For example, why is the income tax on earned income higher than the tax on capital gains or dividends? It did not happen that way under Mrs Thatcher and, according to Jeremy Corbyn’s analysis, this would raise no less than £14 billion. His analysis may not be arithmetically correct, but there is a lot of dibs there for someone seriously looking to be fairer on taxation.

The Prime Minister said that he was fed up with his slogan of “Get Brexit done”, which dominated the campaign, and has banned it from now on. I suggest two further slogans to him, equally simple and equally powerful: “splash the cash” and “level up”.

National Health Service

Lord Horam Excerpts

Thursday 8th January 2015 Lords Chamber

[Lord Horam (Con)]

My Lords, I think we are all very grateful to the noble Lord, Lord Turnberg, for initiating this debate. Obviously, it could not be more timely. He may recall that he and I first met when he was president of the Royal College of Physicians and I was a Minister at the Department of Health. Even then, we had the same post-Christmas problems—we may also be taking the same pills, for all I know, but I will not speculate on that.

I will put forward two particularly positive points as we review the situation, which is obviously worrying, and the longer term situation, which the noble Lord wants us to address. The first is that the NHS remains a good and a tried and trusted model for the delivery of healthcare. If you look around the world, it is very difficult to find one that is better as regards value for money and quality—although we know that there are gaps. It is also, as my noble friend Lord Howe pointed out in his Statement yesterday on the winter problems, remarkably flexible when it needs to be. We see that a number of hospital trusts are coping with these sudden increases in demand in a very innovative and sensible way.

The second positive point I will make is that there is wide consensus—although one would not think so in the political debate that is going on—over the way the NHS should evolve. I will concentrate in my short remarks on the Five Year Forward View, which was produced by Simon Stevens, the chief executive of the National Health Service England, in October last year. That has received general support from all sides of politics, and it was both realistic and sensible. However, the conclusions it reached have been underplayed. The central conclusions Simon Stevens points out in his report’s final two paragraphs are that even if funds remain broadly flat in real-terms increases—and in fact, despite what the noble Lord, Lord Turnberg, said, spending on the National Health Service and on health in this country as a whole has more than doubled in real terms since I was a Minister back in 1997—and if the service continues its annual increases in efficiency of 0.8% a year, which is not a huge annual increase, the £30 billion gap which he envisages by 2020 would reduce to £21 billion. If the increase in efficiency was doubled to 1.5% every year—again, not a huge increase—it would reduce that £30 billion gap to £16 billion. If efficiency could be increased to 2% to 3%, which is quite normal in other industries and services, the funding gap would be almost wholly eliminated and we would be able to reach the nirvana of a continuingly progressive and successful health service.

In that context, I make one suggestion to my noble friend Lord Howe. We know that many hospital beds are occupied by people who do not need to be there, who do not need acute care any longer, and who could be in a recovery situation or intermediate care elsewhere. It is the fact that many housing associations and mental health trusts have been lobbying hospital trusts up and down the country, asking to provide intermediate and recovery units for them, so they can transfer patients from acute services into those intermediate or recovery services. I noticed on the BBC last night that a trawl had been done of where the problems were; a spokesman for Addenbrooke’s Hospital in Cambridge said that 20% of its beds were occupied at this moment by people who could be cared for in a recovery unit or in another form of intermediate care. But the housing associations and mental health trusts are finding that, although very often the chairman and CEOs of hospital trusts are glad to have this support, it is simply impossible to get decisions. The noble Lord, Lord Turnberg, pointed out that among other things it is very difficult and slow to get decisions through the bureaucracy of even the trusts themselves, let alone the overall NHS, and this is causing a real problem.

I hope that my noble friend Lord Howe will look at this issue, where there could be an immediate improvement, within a matter of months, in the number of facilities being taken up by people who do not need to be in hospitals. It would save the capital costs, because housing associations would pay for them out of their own capital funds. It would also save current costs, because an NHS bed costs £2,000 a week to maintain. The housing associations tell me that they could do it for less than £1,000 a week, halving the current costs as well as providing capital money for the NHS. So there is an example of where efficiency savings could be made in a very short space of time. We are talking about months or even a year or two.

Simon Stevens’s conclusion, following the final two paragraphs of his report, was that,

“nothing in the analysis above suggests continuing with a comprehensive tax-funded NHS is intrinsically undoable”.

I believe that to be correct and right, but we will achieve that only if the trusts up and down the country stop being just administered and manage the resources, using the funds available to them properly.

Care Bill [HL]

Lord Horam Excerpts

Wednesday 7th May 2014 Lords Chamber

[Lord Turnbull (CB)]

My Lords, I welcome Amendment 40A and I am grateful to the Minister for listening to representations and responding to them. I always thought it was wrong that a special administrator investigating trust A could try to find a solution by plundering the resources of trust B, which was not in trouble, without giving it or its commissioning group the opportunity to make full representations. I also thought it was wrong that the Secretary of State could slip through what was in effect a restructuring of services in an area under the cloak of sorting out the problems in a particular trust.

However, there is a caveat and an unresolved issue that was hinted at by the noble Lord, Lord Hunt. The provision to put the troubled trust and its neighbours on an equal footing in terms of making representations should not be interpreted as giving other trusts a veto on all restructuring proposals. The present set-up of the NHS already provides more than enough pockets of resistance to change that may be necessary to achieve greater efficiency and higher clinical standards.

Such proposals for reconfiguration should be looked at on their own merits, regardless of whether the hospital concerned is a foundation hospital or has been developed using PFI. There should be no presumption that an error by one trust in the amount of debt it takes on should be visited on those who are unlucky enough to be adjacent to it. There could then be a stalemate at the conclusion of this process whereby the commissioners of the adjacent trust do not agree to surrender resources and services. The question then is how these issues are to be resolved, not simply in the context of the failing trust but in the context of the local health geography.

[Lord Horam (Con)]

My Lords, we owe a debt of gratitude to the noble Baroness, Lady Finlay, for tabling an amendment to this Motion. I was present at the meeting yesterday, along with the noble Lord, Lord Hunt of Kings Heath, when we had a fruitful discussion on these issues. When I was the Member of Parliament for Orpington these matters were the bane of my life. The South London Hospitals Trust was a huge problem, as many noble Lords will be aware, with debts of around £150 million at one stage. Although at another period of my life I was a Minister for Health, I was specifically excluded from dealing with the problems of London hospitals because I was a London MP. It is ironic to get to a position of power where you might actually be able to do something for your constituency but then to be disempowered from dealing with it at all. None the less, that is the proper way to proceed.

It is worth bearing in mind that we have now got to a sensible position whereby there is parity in consultation, understanding and agreement between a commissioning group affected by the hospital trust’s special administrator and one which may be outside the trust and, therefore, nominally unaffected by it. Parity of esteem is the effect of the amendment tabled by the noble Baroness, Lady Finlay. I am grateful to the Minister for responding so positively on these matters: we have now reached a very sensible position. However, we should not believe that that is enough. It is a necessary condition for resolving some of these problems but it is not sufficient. Ironically, in the case of Lewisham and the South London Hospitals Trust, there was a very good consultation, called A Picture of Health, which lasted for two years and encompassed all the hospital trusts in south-east London. It was very extensive—and expensive, if I may say so—but it came to the wrong conclusion. The conclusion was that Lewisham should continue as a hospital trust on its own and that the other three principal hospitals—Queen Elizabeth, Woolwich, Princess Royal University Hospital, Bromley and St Mary’s, Sidcup—should all be put into one huge trust. That never worked and that particular trust has had to have special measures to deal with its financial problems.

That excellent consultation ultimately reached the wrong conclusions. Ironically, the rather more short-circuited consultations conducted by the special administrator led to rather better conclusions. We now have a solution on the Bromley side of things, as it is now a part of King’s College Hospital NHS Trust. It has effectively been taken over by it, which is a very sensible arrangement. St Mary’s, Sidcup is now doing other things—quite rightly because it is an old hospital and did not really have the facilities to run an accident and emergency department in the way that a modern hospital needs to do. Woolwich has been put in with Lewisham. We therefore have the makings of a better solution despite inadequate consultation. It shows that we do not merely need good consultation with everyone understanding what is happening; we need somebody to reach the right conclusions at the end of the day. I am referring here to the remarks made by the noble Lord, Lord Turnbull. He is absolutely right that there needs to be a way that the public interest—as well as the understandable more local interests—can be reflected, otherwise we will never make real progress.

The noble Lord, Lord Hunt, made the important point that there are really big problems. We all have scars resulting from the closure of hospitals that sometimes have to be closed. He will be aware of the report last year by the NHS Confederation, the royal colleges and the organisation representing the patients’ voice, which said that up to 20 general district hospitals in this country need to be closed if we are to have a sustainable hospital service and a sustainable NHS. If we do not close those hospitals over a period, after consultation and so on, we will be taking money away from other parts of the NHS, such as mental health and GP services, which are badly needed. We cannot afford to keep hospitals going when they are in need of change.

The way in which change needs to happen is becoming apparent—there is a general consensus. First, there should be more specialist hospitals. I note that the King’s Fund says that A&E departments, maternity care, neonatal services, heart services and stroke care are all areas where specialist hospitals can give better care than general district hospitals do at the moment. That is already happening in London, certainly in the case of stroke care. The number of hospitals has been reduced and stroke care has immeasurably improved, I think to the tune of 50% over the previous two or three years. Equally, of course, the other aspect of this improvement is bringing care back to the community and taking it away from hospitals. People do not want to go to hospital; they think they will get an infection or a disease, apart from anything else. People die as a consequence of being in hospital. We therefore need to bring care back to the community. However, all of that takes time.

I therefore agree with the noble Lord, Lord Turnbull, that we cannot allow ourselves to get into a situation where everybody defends every brick of every local hospital. We all know what happens. As soon as there is a threat to a local hospital the local MPs and the local newspapers get on their high horse, the campaigners come out and there are parades down the street, and no one can move an inch. I hope that noble Lords can see this legislation in the round. It provides for the proper, equal consultation of all interested parties, but we should not put road blocks in the way of necessary change in the NHS. If we do, we will have done the NHS a very bad service.

[Baroness Brinton]

My Lords, I add the thanks of the Liberal Democrats to those that have already been offered for the help from the Minister and his officials since this matter was last discussed in your Lordships’ House. There have been a number of meetings and an enormous amount of correspondence during that time. A key part of that has been the definition of “consultation”, and how to ensure that services in another trust area rather than only an adjacent area are considered. I am particularly grateful because the amendment tabled by my honourable friend Paul Burstow in the House of Commons is broadly the same as today’s government amendment. I thank him too for his tireless work in expanding this. I very much appreciate the comments made by the noble Lord, Lord Hunt, in his amendment, which try to strengthen that.

However, I am not convinced that there is a need for further strengthening. The committee is there, and I hope that the Minister will be able to confirm that, following the request made by the noble Baroness, Lady Finlay. The committee is there to help set things up and ensure that the progress made as the special administrators start their work takes place in an appropriate fashion, and that every aspect of the consultation—which clearly has worried your Lordships—is addressed.

I want particularly to come back to the point about not considering only adjacent services. Much of the discussion this afternoon has been very focused on London, for fairly obvious reasons. However, there are issues around reconfigurations in rural areas, which do not mimic the pattern of a large number of hospitals in a fairly narrow space. Services may be much more scattered. That is why the word “adjacent”, to which others have referred, is not particularly appropriate. Quite often people will find themselves going not only to one area but beyond that area for a very particular service. It is important that the amendment laid down by the Government today makes it absolutely clear about the extension of consultation with those affected trusts.